The nurse is caring for a group of patients. Which of the the following patients should the nurse evaluate first?
A patient with coronary artery disease (CAD) who reports chest pain radiating to the jaw.
A patient with venous insufficiency with 2+ pitting edema.
A patient receiving enoxaparin (Lovenox) for experiencing an MI 3 days ago.
A patient with peripheral artery disease (PAD) with a diminished pulse.
The Correct Answer is A
A. A patient with coronary artery disease (CAD) who reports chest pain radiating to the jaw: This patient should be evaluated first. Chest pain radiating to the jaw can be a sign of a heart attack, which is a life-threatening condition. Immediate medical attention is required to prevent further damage to the heart muscle.
B. A patient with venous insufficiency with 2+ pitting edema: While this patient’s condition needs to be addressed, it is not as immediately life-threatening as a potential heart attack. Venous insufficiency and edema can lead to discomfort and complications if left untreated, but these complications are typically not immediate.
C. A patient receiving enoxaparin (Lovenox) for experiencing an MI 3 days ago: This patient is already receiving treatment for their condition. While they should be monitored for side effects of the medication and signs of further cardiac issues, they are not the highest priority based on the information given.
D. A patient with peripheral artery disease (PAD) with a diminished pulse: While a diminished pulse can indicate poor blood flow, which can lead to complications such as tissue damage and non-healing wounds, it is not as immediately life-threatening as a potential heart attack. This patient should be evaluated, but they are not the highest priority based on the information given.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
(a) Administer another dose of the beta-blocker as prescribed by the physician: Administering another dose of the beta-blocker may not be the best course of action. If the client is experiencing fatigue and weakness, it could be a sign that the medication’s side effects are causing these symptoms. Administering an additional dose may exacerbate these side effects. Adjusting the medication regimen should be done under the direction of the healthcare provider.
(b) Offer the client a salty snack to improve blood pressure: Offering a salty snack may increase blood pressure, but it does not address the underlying issue of the medication’s side effects. Moreover, a diet high in salt can lead to other health problems, such as heart disease and stroke.
(c) Document the client’s symptoms and notify the healthcare provider: Documenting the client’s symptoms and notifying the healthcare provider is the most appropriate initial nursing action. The healthcare provider needs to be informed so that appropriate changes to the medication regimen can be made.
(d) Encourage the client to participate in physical therapy exercises: While physical therapy exercises can be beneficial for overall health, they do not address the immediate concern of the medication’s side effects. The client’s symptoms are indicative of medication side effects rather than a lack of physical activity. While physical therapy is important, it is not the most immediate priority in addressing the client’s current symptoms.
Correct Answer is ["C","D","E"]
Explanation
A. “Your cholesterol levels should be monitored monthly while taking this medication”: Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor used to treat high blood pressure and heart failure. It does not typically affect cholesterol levels, so monthly cholesterol monitoring is not usually necessary.
B. “Make sure your diet contains a lot of potassium-rich foods.”: While a balanced diet is important for overall health, patients taking lisinopril should be cautious about consuming too much potassium. Lisinopril can increase potassium levels in the body, and consuming too many potassium-rich foods could lead to hyperkalemia, a condition characterized by high levels of potassium in the blood.
C. “Monitor your blood pressure on a regular basis.”: This is correct. Since lisinopril is used to treat high blood pressure, it’s important for patients to monitor their blood pressure regularly to ensure the medication is working effectively.
D. “Notify your doctor immediately if you become pregnant.”: This is correct. Lisinopril is not recommended during pregnancy as it can harm the unborn baby. If a patient becomes pregnant while taking lisinopril, they should notify their doctor immediately.
E. “Report the development of a persistent dry cough.”: This is correct. A persistent dry cough is a common side effect of ACE inhibitors like lisinopril. If a patient develops this symptom, they should report it to their healthcare provider.
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