The nurse on the intermediate care unit received a change-of-shift report on four patients with hypertension. Which patient should the nurse assess first?
52-yr-old with a blood pressure of 198/90 mm Hg who has intermittent claudication.
48-yr-old with a blood pressure of 160/92 mm Hg who reports chest pain.
43-yr-old with a blood pressure of 172/98 mm Hg whose urine shows microalbuminuria.
50-yr-old with a blood pressure of 190/104 mm Hg who has a creatinine of 1.7 mg/dL.
The Correct Answer is B
Among the four patients with hypertension, the nurse should assess the patient in option B first, the 48-year-old with a blood pressure of 160/92 mm Hg who reports chest pain.
Chest pain is a potentially serious symptom that could indicate an acute cardiac event, such as angina or a heart attack. Given that the patient has hypertension and is experiencing chest pain, the nurse must prioritize this assessment to rule out any cardiac-related complications or other urgent issues.
While all the other patients have elevated blood pressure readings, they have additional symptoms or conditions that indicate potential complications related to their hypertension. However, chest pain is a red flag that requires immediate attention and further assessment to determine its cause and provide appropriate interventions promptly.
Option A, the 52-year-old with a blood pressure of 198/90 mm Hg who has intermittent claudication, may have peripheral vascular disease or other vascular issues related to hypertension, but it is not as acutely concerning as chest pain.
Option C, the 43-year-old with a blood pressure of 172/98 mm Hg whose urine shows microalbuminuria, may have early signs of kidney involvement due to hypertension, which is significant and requires attention but may not be as immediately urgent as chest pain.
Option D, the 50-year-old with a blood pressure of 190/104 mm Hg who has a creatinine of 1.7 mg/dL, may have signs of kidney impairment related to hypertension, which is also significant but may not be as acutely urgent as chest pain.
In summary, the nurse should prioritize the assessment of the patient experiencing chest pain (option B) to address any potential cardiac-related issues promptly and ensure appropriate management and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The patient is apneic (not breathing) and has no palpable pulses, indicating a cardiac arrest or severe cardiovascular compromise. In this situation, the most appropriate action for the nurse to take next is to start cardiopulmonary resuscitation (CPR) immediately.
CPR is a life-saving procedure that combines chest compressions and rescue breaths to circulate oxygenated blood to vital organs when the heart is not effectively pumping. In the case of cardiac arrest, early initiation of CPR is critical to improve the chances of survival and minimize potential brain damage.
The heart monitor shows sinus tachycardia, rate 132, which suggests that the electrical impulses are reaching the heart, but the heart is not effectively pumping blood due to the lack of a palpable pulse. This condition requires immediate intervention with CPR rather than other treatments such as synchronized cardioversion (option A) or administering atropine (option D).
While applying supplemental oxygen via a non-rebreather mask (option C) is generally important in many emergency situations, it is not the immediate priority when a patient is apneic and has no palpable pulses. In such cases, CPR takes precedence to restore circulation and maintain oxygen delivery to the body's vital organs.
Correct Answer is A
Explanation
During the 48 hours after a myocardial infarction (MI), the highest priority for monitoring the patient is for dysrhythmias. After an MI, the heart's electrical system can be disrupted, leading to various types of abnormal heart rhythms (dysrhythmias). Dysrhythmias can be life-threatening and require prompt recognition and intervention.
Other options:
B) Anxiety and fear: Anxiety and fear are common emotional responses after an MI, but they are not the highest priority for monitoring during the immediate post-MI period. Emotional support and counseling are essential, but they do not require continuous monitoring.
C) Metabolic acidosis: Metabolic acidosis is not a common complication of an acute MI. It may occur in certain situations, such as when there is inadequate perfusion to tissues, but it is not the highest priority during the immediate post-MI period.
D) Medication side effects: Monitoring for medication side effects is important but is not the highest priority during the immediate post-MI period. Many patients will receive medications to manage pain, reduce clot formation, and stabilize their heart function. The nurse should monitor for side effects but not as a higher priority compared to dysrhythmias.
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