The nurse is responsible for the care of four patients.
Which patient should the nurse assess first?

A patient with sinus bradycardia, heart rate of 48, awaiting pacemaker placement.

A patient admitted 1 hour ago with new onset Atrial Fibrillation who is receiving diltiazem.

A patient admitted one day ago with thrombophlebitis who is receiving IV heparin.

A patient with end-stage, right-sided heart failure with blood pressure of 78/50 who is on hospice care

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Sinus bradycardia with a heart rate of 48 is a potentially life-threatening condition that requires immediate assessment and intervention. The heart rate is significantly below the normal range of 60-100 beats per minute, which means that the heart is not pumping enough blood to meet the body's needs. This can lead to symptoms such as dizziness, lightheadedness, fatigue, shortness of breath, chest pain, and even syncope (fainting). In severe cases, it can progress to cardiac arrest and death.

The patient is awaiting pacemaker placement, indicating that the bradycardia is severe and not responding to other treatment measures. This further underscores the urgency of assessment and intervention.

The nurse needs to assess the patient immediately for signs of hemodynamic instability, such as hypotension, altered mental status, and decreased urine output. The nurse should also obtain a 12-lead ECG to confirm the diagnosis of sinus bradycardia and to rule out other potential causes of the bradycardia, such as AV block or medication effects.

Prompt intervention is crucial to prevent further deterioration of the patient's condition and to avoid potentially lifethreatening complications.

Choice B rationale:

Atrial fibrillation is a common heart rhythm disorder that is characterized by rapid and irregular beating of the heart's upper chambers (atria). It can cause symptoms such as palpitations, shortness of breath, fatigue, and lightheadedness.

Diltiazem is a calcium channel blocker that is often used to control the heart rate in patients with atrial fibrillation. While it is important to monitor patients who are newly started on diltiazem for potential side effects, such as hypotension and bradycardia, it is not as urgent as assessing a patient with severe sinus bradycardia.

Choice C rationale:

Thrombophlebitis is an inflammation of a vein that is often caused by a blood clot. It can cause pain, redness, swelling, and warmth in the affected area.

IV heparin is an anticoagulant medication that is used to prevent blood clots from forming or getting larger. While it is important to monitor patients who are receiving IV heparin for potential side effects, such as bleeding, it is not as urgent as assessing a patient with severe sinus bradycardia.

Choice D rationale:

End-stage, right-sided heart failure is a serious condition that is characterized by the inability of the heart to pump blood effectively from the right ventricle to the lungs. It can cause symptoms such as shortness of breath, fatigue, edema, and abdominal swelling.

Hospice care is a type of care that focuses on providing comfort and quality of life for patients who are nearing the end of life. While it is important to provide supportive care for patients who are on hospice care, it is not as urgent as assessing a patient with severe sinus bradycardia.

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Correct Answer is ["A","C","D"]

Explanation

Choice A rationale:

Duration of pain: Stable angina typically lasts for less than 5 minutes, while pain from a myocardial infarction (MI) typically lasts longer, often 20 minutes or more. This is because stable angina is caused by a temporary decrease in blood flow to the heart muscle, while an MI is caused by a complete blockage of blood flow, leading to more severe and prolonged pain.

Mechanism of pain: The pain in stable angina is due to ischemia, which is a lack of oxygen to the heart muscle. This occurs when the demand for oxygen by the heart muscle exceeds the supply of oxygenated blood.

Nitrates and ischemia: Nitrates, such as nitroglycerin, work by dilating the coronary arteries, which increases blood flow to the heart muscle and relieves ischemia. This is why nitroglycerin is often effective in relieving the pain of stable angina.

Choice B rationale:

Non-specific symptom: Shortness of breath can occur with both stable angina and MI, as well as other conditions such as lung disease or anxiety. Therefore, it is not a specific symptom that can be used to differentiate between the two conditions.

Choice C rationale:

Activity level: Stable angina is typically triggered by exertion or emotional stress, which increase the heart's demand for oxygen.

Rest and angina: The pain often subsides with rest or nitroglycerin.

MI and rest: In contrast, the pain of an MI can occur at rest and is not always relieved by nitroglycerin.

Choice D rationale:

Nitrates and stable angina: As mentioned earlier, nitrates are often effective in relieving the pain of stable angina.

Nitrates and MI: However, they may not be as effective in relieving the pain of an MI, as the blockage of blood flow is more severe.

A. Repolarization B. Systole C. Diastole D. Ejection fraction

Correct Answer is B

Explanation

Choice A Rationale:

Repolarization is a phase in the cardiac cycle that involves the restoration of electrical charges in heart muscle cells, enabling them to prepare for the next contraction. It does not directly refer to the physical contraction and ejection of blood from the chambers.

During repolarization, the heart muscle cells regain their negative electrical charge after depolarization, which triggered the contraction.

Repolarization is essential for maintaining the heart's rhythmic electrical activity and ensuring coordinated contractions.

It does not, however, cause the chambers to become smaller and eject blood, which is the defining feature of systole.

Choice C Rationale:

Diastole is the phase of the cardiac cycle when the heart chambers relax and fill with blood. It is the opposite of systole.

During diastole, the heart muscle relaxes, allowing the chambers to passively expand and collect blood from the veins.

The atrioventricular valves (mitral and tricuspid valves) open during diastole, allowing blood to flow from the atria into the ventricles.

While diastole is crucial for ensuring adequate blood supply to the heart, it does not involve the forceful ejection of blood into circulation that characterizes systole.

Choice D Rationale:

Ejection fraction is a measurement of the heart's pumping efficiency. It represents the percentage of blood that is ejected from the left ventricle with each contraction.

A normal ejection fraction is typically between 55% and 70%.

While ejection fraction is related to systole, it is not a synonym for it. Ejection fraction is a quantitative measure of how well the heart is pumping, while systole refers to the specific phase of the cardiac cycle when contraction and ejection occur.

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The nurse is responsible for the care of four patients. Which patient should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is evaluating a patient who is experiencing chest pain beneath the sternum. Which symptom reports would support a diagnosis of stable angina pectoris over a potential myocardial infarction? (Select All That Apply)

Correct Answer is ["A","C","D"]

Explanation

A nurse is describing the process by which blood is ejected into circulation as the chambers of the heart become smaller. How does the nurse categorize this action of the heart?

Correct Answer is B

Explanation

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The nurse is responsible for the care of four patients.
Which patient should the nurse assess first?