A nurse receives report on four clients at the beginning of the shift. Which of the following clients should the nurse place priority on assessing first?
A client who had a myocardial infarction two days ago, and complains of soft stools after taking docusate sodium.
A client being treated for thrombotic thrombocytopenic purpura (TTP) who has had 120 mL of urine output in the last 12 hours.
A client who was admitted for premature atrial contractions (PACS) and whose most recent blood pressure is 148/89.
A client receiving furosemide for heart failure whose daily weight shows that he has lost 0.5 kg since yesterday.
The Correct Answer is B
A. While soft stools after taking docusate sodium is noteworthy, it is not immediately life-threatening and does not require urgent intervention.
B. Oliguria (low urine output) in a client with TTP is concerning because it may indicate acute kidney injury or worsening of the condition, requiring immediate assessment and intervention.
C. An elevated blood pressure in a client with PACs is important but not as critical as potential kidney dysfunction in the TTP patient.
D. A weight loss of 0.5 kg in a client with heart failure on furosemide may be expected and does not require immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. NSTEMI would present with elevated troponin levels indicating myocardial injury, which is not the case here.
B. Stable angina occurs predictably with exertion and is relieved by rest or nitroglycerin.
C. STEMI is characterized by ST-elevation on the ECG and elevated troponin levels, indicating significant myocardial injury.
D. Unstable angina presents with chest pain that occurs at rest or with minimal exertion and is not predictable. The presence of T-wave inversion and normal troponin levels is consistent with this diagnosis.
Correct Answer is D
Explanation
A. Apixaban is an anticoagulant used to prevent clot formation and reduce stroke risk, not specifically to reduce bleeding risk.
B. Rate control is typically achieved with medications like beta-blockers or calcium channel blockers, not anticoagulants like apixaban.
C. Apixaban does not convert heart rhythm; it prevents blood clots.
D. The primary purpose of apixaban in patients with atrial fibrillation is to reduce the risk of stroke by preventing blood clot formation.
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