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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Lisinopril is not used to reduce LDL cholesterol and triglycerides; statins are used for that purpose.
B. Lisinopril does not prevent platelet aggregation; antiplatelet agents like aspirin are used for that purpose.
C. Lisinopril is not used to relieve acute angina; nitrates like nitroglycerin are used for that purpose.
D. Lisinopril is an ACE inhibitor that helps decrease blood pressure and reduce the workload on the heart, which is beneficial in managing chronic stable angina.

A. Educate the client to go to the hospital if she experiences alopecia after receiving this medication. B. Administer loperamide to prevent chemotherapy-induced nausea. C. Assess the client's skin for desquamation caused by this medication. D. Review the results of the client's most recent echocardiogram.

Correct Answer is D

Explanation

A. Alopecia is a common side effect of chemotherapy but does not necessitate immediate hospital visit.
B. Loperamide is used to treat diarrhea, not nausea. Antiemetics are used for chemotherapy-induced nausea.
C. Desquamation is not a typical side effect of daunorubicin; skin assessment is not the primary concern.
D. Daunorubicin can cause cardiotoxicity; therefore, reviewing the client's most recent echocardiogram is essential to assess cardiac function before administration.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who has been diagnosed with chronic stable angina is placed on multiple medications to manage the condition. The nurse understands that the client is receiving lisinopril for which reason?

Correct Answer is D

Explanation

A nurse on an oncology unit is preparing to administer daunorubicin to a client who has leukemia. Which action should the nurse take before administering this medication?

Correct Answer is D

Explanation

The nurse is caring for a client who has left-sided heart failure. Which statement made by the patient would be consistent with left-sided heart failure?

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