Upon receiving a change-of-shift report about four patients in a heart failure unit, which patient should the nurse prioritize for assessment?

A patient who experienced dizziness after the first dose of captopril.

A patient exhibiting new-onset confusion, restlessness, and cool, clammy skin.

A patient on oxygen therapy with bilateral crackles at the lung bases.

A patient on IV nesiritide (Natrecor) with a blood pressure reading of 100/62.

Answer and Explanation

The Correct Answer is B

Choice A rationale
While dizziness after the first dose of captopril can be concerning, it is not uncommon as the body adjusts to the medication. It is important to monitor this patient, but they are not the highest priority.
Choice B rationale
A patient exhibiting new-onset confusion, restlessness, and cool, clammy skin should be prioritized for assessment. These symptoms could indicate a serious condition such as shock or decreased cardiac output. This patient may be experiencing a rapid decline in condition and should be assessed immediately.
Choice C rationale
While a patient on oxygen therapy with bilateral crackles at the lung bases may have worsening heart failure, they are not the highest priority if they are stable. Crackles at the lung bases are a common finding in heart failure and indicate fluid accumulation in the lungs.
Choice D rationale
A patient on IV nesiritide (Natrecor) with a blood pressure reading of 100/62 is not the highest priority. While this blood pressure is on the lower side, it is not critically low.
Nesiritide can cause hypotension, so this patient should be monitored, but they are not the highest priority if they are stable.

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Correct Answer is D

Explanation

The correct answer is Choice D.

Choice A rationale: Allergies to shellfish may indicate iodine allergy, relevant for procedures using iodine-based contrast, like PCI. The client’s shellfish allergy must be reported to the PHCP as a precautionary measure to prevent any allergic reaction.

Choice B rationale: Warm sensations during PCI are a common side effect of the contrast dye used in the procedure. This statement does not indicate an immediate concern requiring PHCP notification as it is a standard patient experience.

Choice C rationale: Anxiety in closed spaces, known as claustrophobia, may affect the client's comfort during PCI but can be managed with sedatives. The PHCP should be aware but it’s not as urgent as taking contraindicated medications.

Choice D rationale: Metformin can lead to lactic acidosis, especially when iodine contrast dye is used during PCI. This condition is serious and may result in adverse interactions. The PHCP must be notified immediately.

A. Ventricular septal defect (VSD) B. Atrioventricular canal (AVC) defect C. Tetralogy of Fallot D. Atrial septal defect (ASD)

Correct Answer is C

Explanation

Choice A rationale
A Ventricular Septal Defect (VSD) is a hole in the wall separating the two lower chambers of the heart. While it can cause cyanosis, it’s typically not associated with cyanosis during crying or feeding.
Choice B rationale
An Atrioventricular Canal (AVC) defect is a combination of heart problems resulting in a defect in the center of the heart. While it can cause cyanosis, it’s typically not associated with cyanosis during crying or feeding.
Choice C rationale
Tetralogy of Fallot is a congenital heart condition characterized by four anatomical abnormalities of the heart. It is the most common cyanotic heart defect and the most common cause of blue baby syndrome. Cyanosis, which is caused by a lack of oxygen in the blood, is often seen during periods of activity, such as feeding or crying.
Choice D rationale
An Atrial Septal Defect (ASD) is a hole in the wall between the two upper chambers of your heart (atria). While it can cause cyanosis, it’s typically not associated with cyanosis during crying or feeding.

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Upon receiving a change-of-shift report about four patients in a heart failure unit, which patient should the nurse prioritize for assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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