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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

(A) Determine the client’s blood pressure 1 min after each position change: While it’s important to check the client’s blood pressure after each position change when assessing for orthostatic hypotension, this is not the first step. The nurse should first establish a baseline blood pressure reading with the client in a supine position.

(B) Place the client in a sitting position: Although the nurse will eventually need to check the client’s blood pressure in a sitting position, the first step is to get a baseline reading with the client in a supine position.

(C) Assist the client into a standing position: The nurse will eventually assist the client into a standing position to check for changes in blood pressure, but this is not the first step. The initial step is to get a baseline reading with the client in a supine position.

(D) Check the blood pressure with the client in a supine position: This is the most appropriate first step. When checking for orthostatic hypotension, the nurse should first check the client’s blood pressure while they are lying flat (supine). This provides a baseline reading against which subsequent readings (taken when the client is sitting and standing) can be compared. If there’s a significant drop in blood pressure upon standing, this could indicate orthostatic hypotension.

A. "C" refers to the cost to complete the research. B. "O" refers to the outcome of the research. C. "I" refers to the issue to be researched. D. "T" Prefers to the steps for planning the research

Correct Answer is B

Explanation

A. “C” refers to the cost to complete the research: This is not accurate. In a PICOT question, “C” stands for “Comparison”. It refers to the other main intervention or treatment that you wish to compare with the intervention12.

B. “O” refers to the outcome of the research: This is correct. In a PICOT question, “O” stands for “Outcome”. It refers to the effect or result that you expect from the intervention12.

C. “I” refers to the issue to be researched: This is not accurate. In a PICOT question, “I” stands for “Intervention”. It refers to the treatment or action that the researcher wants to study12.

D. “T” Prefers to the steps for planning the research: This is not accurate. In a PICOT question, “T” stands for “Time”. It refers to the time it takes for the intervention to achieve the outcome or how long patients are observed

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The nurse is caring for a group of patients. Which of the the following patients should the nurse evaluate first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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