The nurse is caring for a team of assigned clients. Which client is a priority for the nurse to check on first?
The client with a history of a myocardial infarction who has a p wave before every QRS complex.
The client diagnosed with heart failure who has bilateral 2+ pitting pedal edema.
The client with sinus bradycardia (HR 56/min) that is reporting fatigue.
The client diagnosed with coronary artery disease who is now reporting new onset of severe indigestion.
The Correct Answer is D
A. The client with a history of a myocardial infarction who has a p wave before every QRS complex.
This may indicate a heart block, which requires attention. However, it's not an immediate life-threatening situation.
B. The client diagnosed with heart failure who has bilateral 2+ pitting pedal edema.
Bilateral pitting pedal edema is a sign of fluid overload, which is concerning and requires attention.
C. The client with sinus bradycardia (HR 56/min) that is reporting fatigue.
While bradycardia and fatigue are concerns, they might not be as urgent as the client with fluid overload.
D. The client diagnosed with coronary artery disease who is now reporting new onset of severe indigestion.
New onset of severe indigestion in a client with coronary artery disease raises concern for a potential cardiac event, and this should be addressed promptly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The patient pain reflects the target heart rate has been set too high and needs to be lowered to finish the test.
This option suggests that the chest pain is related to the target heart rate being set too high. However, chest pain during an exercise stress test is more commonly associated with myocardial ischemia rather than an inappropriate target heart rate. Lowering the target heart rate may not address the underlying issue of ischemia.
B. The patient’s pain reflects pericarditis and the test should be stopped.
Chest pain during an exercise stress test is more commonly associated with myocardial ischemia rather than pericarditis. Pericarditis is inflammation of the pericardium, and its symptoms may include chest pain that is often sharp and pleuritic. However, during an exercise stress test, the focus is on detecting cardiovascular abnormalities, and chest pain is more concerning for ischemia.
C. The patient’s pain reflects ischemia to the myocardium and the test should be stopped.
This is the most appropriate interpretation. Chest pain during an exercise stress test may indicate insufficient oxygen supply to the myocardium (ischemia). Stopping the test allows for further evaluation and appropriate intervention.
D. The patient’s pain reflects that supplemental oxygen is needed to finish the test.
Chest pain during an exercise stress test is not typically addressed by providing supplemental oxygen. Stopping the test and evaluating the cause of the chest pain is a more appropriate action.
Correct Answer is D
Explanation
A. Visible clubbing of the fingers and toes
Clubbing is a condition characterized by changes in the shape and appearance of the fingers and toes. It involves enlargement of the fingertips and the nails becoming curved and rounded. Clubbing is not typically associated with peripheral arterial occlusive disease (PAD). It is more commonly seen in conditions such as chronic respiratory or cardiovascular diseases.
B. Unequal peripheral pulses between extremities
Unequal peripheral pulses can be indicative of vascular abnormalities. However, in PAD, the characteristic finding is diminished or absent pulses rather than unequal pulses between extremities. Other conditions, such as arterial embolism or thrombosis, may present with unequal pulses.
C. Reddened extremities with muscle atrophy
Reddened extremities and muscle atrophy are not typical findings in PAD. These symptoms are more characteristic of conditions associated with chronic inflammation or compromised venous circulation, such as chronic venous insufficiency or venous stasis.
D. Loss of hair on the distal extremities
Loss of hair on the distal extremities, particularly on the lower legs and feet, is a common finding in PAD. It results from reduced blood flow and oxygen supply to the hair follicles in the affected areas.
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