The nurse on the intermediate care unit received change-of-shift report on four clients with hypertension. Which patient should the nurse assess ﬁrst?

A client with a blood pressure of 190/92 mm Hg who reports chest pain

A client with a blood pressure of 190/104 mm Hg who has sinus tachycardia

A client with a blood pressure of 178/90 mm Hg who has intermittent claudication

A client with a blood pressure of 172/98 mm Hg scheduled for a stress test

Answer and Explanation

The Correct Answer is A

The nurse should assess the client with a blood pressure of 190/92 mm Hg who reports chest pain ﬁrst. Chest pain can be a symptom of myocardial ischemia or a heart attack, which requires immediate attention. The combination of high blood pressure and chest pain is concerning and may indicate acute coronary syndrome. Prompt assessment and intervention are crucial to evaluate the cause of the chest pain and initiate appropriate treatment.

A client with a blood pressure of 190/104 mm Hg who has sinus tachycardia: While sinus tachycardia may indicate increased heart rate, it does not necessarily require immediate assessment unless other concerning symptoms are present. However, the nurse should address the elevated blood pressure in a timely manner.

Intermittent claudication refers to leg pain or discomfort during physical activity due to reduced blood ﬂow. While it is important to assess and manage this symptom, it is not typically considered an urgent condition requiring immediate assessment compared to chest pain.

The client scheduled for a stress test may have elevated blood pressure, but if they are stable and not currently experiencing symptoms, they may not require immediate assessment compared to a client with chest pain.

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Correct Answer is D

Explanation

Monitoring a client after a transesophageal echocardiogram involves observing the client for any immediate post-procedure complications or adverse reactions. This may include assessing vital signs, monitoring for signs of bleeding or infection, and reporting any concerning symptoms or changes in the client's condition to the nurse.

Checking the client's catheter site after a coronary angiogram requires assessing the site for bleeding, hematoma, or signs of infection. This task involves more complex assessment skills and would typically be performed by the nurse.

Teaching a patient about exercise electrocardiography involves providing education on the purpose of the test, the procedure itself, and any preparation or precautions the patient needs to take. This task requires specialized knowledge and is best performed by the nurse who can address the patient's specific questions and concerns.

Attaching ECG monitoring electrodes after a patient bathes requires technical knowledge and skill in properly placing the electrodes and ensuring accurate ECG readings. This task also falls within the scope of the nurse's responsibilities.

Delegation should be based on the UAP's skill set, training, and the complexity of the task. While the UAP can provide valuable support in monitoring a client after a transesophageal echocardiogram, the other tasks mentioned require the expertise and knowledge of a nurse.

A. "My feet feel like I have pins and needles." B. "When I stand or sit too long, my feet swell." C. "My legs get a painful cramp when I walk over 30 minutes." D. "I get short of breath when I climb a lot of stairs.”

Correct Answer is C

Explanation

The client statement that supports the information of intermittent claudication is: "My legs get a painful cramp when I walk over 30 minutes.": Intermittent claudication is a symptom of peripheral artery disease (PAD) characterized by pain, cramping, or fatigue in the muscles of the lower extremities, typically the calves, thighs, or buttocks. This pain is usually triggered by physical activity, such as walking, and is relieved with rest. The pain is caused by inadequate blood flow and oxygen supply to the muscles due to narrowed or blocked arteries.

The other client statements do not specifically indicate intermittent claudication:

"My feet feel like I have pins and needles": This sensation of pins and needles is often associated with peripheral neuropathy, which is a condition involving nerve damage and does not directly relate to intermittent claudication.

"When I stand or sit too long, my feet swell": This statement suggests the possibility of venous insufficiency rather than intermittent claudication. Venous insufficiency involves impaired blood return from the legs to the heart and may result in swelling, aching, or heaviness in the legs.

"I get short of breath when I climb a lot of stairs": This symptom is more indicative of cardiovascular or respiratory issues, such as heart or lung disease, rather than intermittent claudication. It suggests that the client may experience exercise intolerance due to cardiopulmonary limitations.

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The nurse on the intermediate care unit received change-of-shift report on four clients with hypertension. Which patient should the nurse assess ﬁrst?

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Naxlex Comprehensive Predictor Exams

The nurse and unlicensed assistive personnel (UAP) on the telemetry unit are caring for four clients. Which nursing action can be delegated to the UAP?

Correct Answer is D

Explanation

A nurse is assessing a client with intermittent claudication. What client statement supports this information?

Correct Answer is C

Explanation

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