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

Choice A rationale
Atrial Flutter is a type of arrhythmia where the atria beat regularly, but much faster than usual. The treatment for Atrial Flutter is typically medication, not cardioversion.
Choice B rationale
Ventricular Tachycardia is a fast, abnormal heart rate. It starts in your heart’s lower chambers, or ventricles. Ventricular Tachycardia is a serious condition and can be life-threatening. While cardioversion can be used in some cases, it is not the primary treatment.
Choice C rationale
Atrial Fibrillation is when the upper chambers of the heart (atria) beat irregularly. This causes the atria to twitch, leading to an abnormal heart rhythm. The treatment for Atrial Fibrillation is typically medication, not cardioversion.
Choice D rationale
Ventricular Fibrillation is a life-threatening heart rhythm that results in a rapid, erratic heartbeat. During Ventricular Fibrillation, the heart quivers and can’t pump any blood, causing cardiac arrest. The treatment for Ventricular Fibrillation is Defibrillation.

A. Administer Ibuprofen as scheduled. B. Monitor the patient for complications of cardiac tamponade. C. Place the patient in a supine position to relieve pain. D. Monitor the patient for pulsus paradoxus and muffled heart sounds.

Correct Answer is C

Explanation

Choice A rationale
Administering Ibuprofen as scheduled is a proper nursing intervention for a patient with pericarditis. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can help reduce inflammation and relieve pain.
Choice B rationale
Monitoring the patient for complications of cardiac tamponade is a proper nursing intervention for a patient with pericarditis. Cardiac tamponade is a serious condition that can occur as a complication of pericarditis.
Choice C rationale
Placing the patient in a supine position to relieve pain is not a proper nursing intervention for a patient with pericarditis. This position could actually increase the patient’s discomfort.
Instead, the patient should be positioned upright and leaning forward to help relieve pain.
Choice D rationale
Monitoring the patient for pulsus paradoxus and muffled heart sounds is a proper nursing intervention for a patient with pericarditis. These are potential signs of worsening pericarditis or complications such as cardiac tamponade.

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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

A nurse in the Emergency Department is evaluating a patient’s cardiac rhythm. What is the correct interpretation of the rhythm and the appropriate treatment?

Correct Answer is D

Explanation

You are providing care to a patient with pericarditis. Which of the following is NOT a proper nursing intervention for this patient?

Correct Answer is C

Explanation

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