A nurse is caring for a client who has a history of angina.
Which of the following findings require follow-up by the nurse? Select all that apply.
Blood pressure
Anxiety
Oxygen saturation
Breath sounds
Irregular heart rate
Chest tightness
Correct Answer : A,C,E,F
A. Blood pressure: A significant drop from 118/76 mmHg to 88/56 mmHg indicates hypotension, which can compromise perfusion. This requires urgent follow-up because it may reflect cardiogenic shock or myocardial infarction complications.
B. Anxiety: Anxiety is a common response to chest pain and shortness of breath. While it should be acknowledged, it is not the priority compared to hemodynamic instability and hypoxemia.
C. Oxygen saturation: The drop from 98% to 88% on room air shows hypoxemia. This requires immediate follow-up, as low oxygen levels increase cardiac workload and worsen myocardial ischemia.
D. Breath sounds: Bilateral breath sounds remain clear and unchanged between assessments. This finding does not require follow-up since there is no evidence of pulmonary congestion or abnormal sounds.
E. Irregular heart rate: The shift from a regular rate of 78 bpm to an irregular, rapid rate of 128 bpm signals a new arrhythmia. This significantly impacts cardiac output and requires immediate follow-up.
F. Chest tightness: Chest pain radiating to the jaw and unrelieved by rest suggests unstable angina or myocardial infarction. This is a critical symptom requiring urgent evaluation and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The right second intercostal space: This area corresponds to the aortic valve area, not the pulmonic valve area. Palpation here would assess for pulsations related to the aortic region rather than the pulmonic.
B. The left fifth intercostal space: This location is too low and corresponds more closely to the tricuspid area if near the sternum. It does not provide assessment data for the pulmonic valve.
C. The left second intercostal space: The pulmonic valve area is located at the left second intercostal space near the sternal border. This is the correct site for palpating unexpected pulsations associated with the pulmonic area.
D. The left fifth intercostal space at the midclavicular line: This area is where the apical impulse, or point of maximal impulse (PMI), is palpated. It reflects left ventricular activity, not the pulmonic valve.
Correct Answer is B
Explanation
A. It produces vitamin D: The large intestine does not play a role in vitamin D production. Vitamin D is synthesized in the skin with sunlight exposure and processed by the liver and kidneys, not the colon.
B. It absorbs liquid to form stool: The large intestine absorbs water and electrolytes from indigestible food matter. This process compacts the waste into stool for eventual elimination, which is its primary function.
C. It secretes enzymes to digest food: Enzyme secretion for digestion occurs mainly in the stomach and small intestine. The large intestine’s role is absorption and bacterial fermentation, not enzyme-driven digestion.
D. It prevents the reflux of food into the esophagus: Prevention of reflux is the function of the lower esophageal sphincter, not the large intestine. The colon is much lower in the gastrointestinal tract and unrelated to this function.
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