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 B
Explanation
A. Maintaining a diet high in dairy to increase protein necessary to prevent organ damage
Explanation: This statement is not accurate. While a balanced diet is important, there is no specific recommendation to maintain a diet high in dairy to prevent organ damage related to hypertension.
B. Use of strategies to prevent falls stemming from postural hypotension
Explanation: This is a correct and important consideration. Beta-blockers can cause postural hypotension (a drop in blood pressure upon standing), and strategies to prevent falls, such as rising slowly from a sitting or lying position, are crucial.
C. Limiting exercise to avoid injury that can be caused by increased intracranial pressure
Explanation: This statement is not accurate. Exercise is generally beneficial for individuals with hypertension, and beta-blockers do not cause increased intracranial pressure.
D. Increasing fluids to avoid extracellular volume depletion from the diuretic effects of the beta-blocker
Explanation: This statement is not accurate. Beta-blockers are not typically associated with diuretic effects. Diuretics are a different class of medications commonly used for hypertension.
Correct Answer is A
Explanation
A. “I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet.”
Explanation: This statement reflects an understanding of the association between smoking and reduced blood flow, particularly due to nicotine's vasoconstrictive effects.
B. “The older I get the higher my risk for peripheral arterial disease gets.”
Explanation: While age is a non-modifiable risk factor for PAD, it is not a statement indicating a change in behavior to address risk factors. It is correct information but doesn't involve a proactive approach to risk reduction.
C. “Since my family is from Italy, I have a higher risk of developing peripheral arterial disease.”
Explanation: Family history is a non-modifiable risk factor, and the statement correctly identifies this risk factor. However, it doesn't address modifiable factors or actions to reduce risk.
D. “I will need to increase the amount of green leafy vegetables I eat to lower my cholesterol levels.”
Explanation: This statement demonstrates an understanding of a dietary modification to lower cholesterol levels, which is a positive step toward reducing a modifiable risk factor for PAD.
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