A client with chronic stable angina reports a new onset of shortness of breath at rest. The nurse obtains vital signs and records a heart rate of 168 beats/minute, respiratory rate 26 breaths/minute, and blood pressure 124/76 mm Hg. While waiting for an electrocardiogram (ECG), which assessment is most important for the nurse to obtain?

Rhythm of apical heart rate.

Volume of pedal pulses.

Degree of skin elasticity.

Length of capillary refill.

Answer and Explanation

The Correct Answer is A

A. Rhythm of apical heart rate: Assessing the rhythm of the apical heart rate is most important, especially with a rate of 168 bpm. This could indicate a tachydysrhythmia (e.g., atrial fibrillation with rapid ventricular response or supraventricular tachycardia) contributing to the new shortness of breath.

B. Volume of pedal pulses: Although assessing peripheral perfusion is important, pedal pulses are not the priority in the context of a dangerously high heart rate and new respiratory symptoms.

C. Degree of skin elasticity: Skin turgor evaluates hydration but is not directly relevant in the setting of acute cardiac symptoms. It does not provide timely data to explain the new-onset shortness of breath or tachycardia.

D. Length of capillary refill: Capillary refill is a general indicator of perfusion, but it is less specific and immediate compared to assessing the heart rhythm. It may be slightly delayed in this case but won’t clarify the underlying cardiac issue.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Headache with sudden onset: While a sudden headache can be concerning and suggest a neurologic issue, it is not the most immediate sign of hemodynamic instability in the context of atrial fibrillation with hypotension. The priority is assessing cerebral perfusion.

B. Flat jugular vein distention (JVD) at 45 degrees: Flat JVD may reflect low central venous pressure, which is consistent with hypotension but is not as critical as changes in neurologic status. It is a supportive finding rather than a primary indicator to report.

C. Abnormal level of consciousness: Altered mental status indicates reduced cerebral perfusion due to a dangerously low cardiac output from rapid atrial fibrillation and hypotension. This is a critical, life-threatening sign that demands immediate medical intervention to restore adequate perfusion.

D. Nausea with vomiting: These symptoms can occur with hypotension or sympathetic stimulation but are nonspecific and less urgent compared to neurologic compromise. They do not require the same immediate action as a change in consciousness.

A. Unilateral calf pain. B. Intravenous site inflammation. C. Pedal edema. D. Difficulty breathing.

Correct Answer is D

Explanation

A. Unilateral calf pain: This is a classic sign of DVT, indicating localized clot formation in the leg. While significant, it is not as immediately life-threatening as signs of pulmonary embolism and does not require urgent reporting if PE is already suspected.

B. Intravenous site inflammation: IV site inflammation may suggest phlebitis or local irritation but is not related to the acute life-threatening nature of pulmonary embolism. It should be addressed but does not warrant immediate escalation over respiratory symptoms.

C. Pedal edema: Pedal edema is a common finding in DVT or chronic venous insufficiency and may be present without acute complications. Although it supports the history of venous thromboembolism, it is not urgent unless associated with other signs of decompensation.

D. Difficulty breathing: Sudden onset dyspnea is a hallmark symptom of pulmonary embolism and may signal impaired gas exchange or hemodynamic compromise. This finding must be reported immediately as it indicates potential life-threatening embolic obstruction in the pulmonary circulation.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has developed atrial fibrillation with a ventricular rate of 150 beats/minute observed via telemetry. The client's blood pressure is 80/40 mm Hg. Which finding is most important for the nurse to report to the healthcare provider?

Correct Answer is C

Explanation

The nurse is assessing a client with a history of deep vein thrombosis (DVT) who is admitted for possible pulmonary embolism (PE). It is important to report which finding to the healthcare provider immediately?

Correct Answer is D

Explanation

Following cardiopulmonary resuscitation (CPR) and multiple defibrillations, the client's blood is drawn for STAT analysis. The client's heart rate is 130 beats/minute with ST elevation. Which of the client's serum laboratory values is most important for the nurse to monitor?

A client who is experiencing chest pain and an ST elevation in leads II, III, and aVF is receiving an infusion of tissue plasminogen activator (tPA). Which assessment finding warrants immediate intervention by the nurse?

Exhibits The client's electrocardiogram (ECG) strip reveals sinus tachycardia. Select the 4 characteristics that the nurse is likely to see in the ECG.

A client is admitted to the hospital for shortness of breath and chest pain after an episode of syncope. Which laboratory finding is most important for the nurse to report to the healthcare provider (HCP)?

When conducting discharge teaching for a client who has had a mechanical valve replacement, which information should the nurse plan to include?

The healthcare provider (HCP) prescribes naloxone HCI 10 mcg IV bolus stat. Naloxone HCL is supplied as "0.02 mg/mL." How many mL should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

Following a mitral valve replacement, the client suddenly begins to show a large amount of blood on the surgical dressing while in the postanesthesia care unit (PACU). Which intervention should the nurse implement first?

A client with a history of anxiety and asthma had an open cholecystectomy 3 days ago. Shortly after ambulating to the bathroom, the client is restless and troubled by shortness of breath. Which action should the nurse implement first?