A patient who has chronic heart failure is admitted to the emergency department with severe dyspnea and a dry, hacking cough. Which action would the nurse take first?.
Auscultate the breath sounds.
Check the capillary refill.
Auscultate the abdomen.
Ask about the patient's allergies.
The Correct Answer is A
Choice A rationale:
In a patient with severe dyspnea and a dry, hacking cough, auscultating the breath sounds would be the first action to assess for any abnormalities.
Choice B rationale:
Checking the capillary refill would not be the first action as it does not directly relate to the symptoms of severe dyspnea and a dry, hacking cough.
Choice C rationale:
Auscultating the abdomen would not be the first action as it does not directly relate to the symptoms of severe dyspnea and a dry, hacking cough.
Choice D rationale:
Asking about the patient’s allergies would not be the first action as it does not directly relate to the symptoms of severe dyspnea and a dry, hacking cough.
So, the correct answer is A, after analyzing all choices.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","F"]
Explanation
Choice A rationale:
The client’s temperature decreased from 37.6°C to 36.8°C1. This is within the normal body temperature range of 36.5°C to 37.2°C2, so it does not require further action.
Choice B rationale:
The client’s oxygen saturation decreased from 95% to 88%1. Normal pulse oximetry values are typically above 95%2. This decrease could indicate that the client is not getting enough oxygen, which requires further action.
Choice C rationale:
The client’s blood pressure increased from 108/50 mm Hg to 138/80 mm Hg. Normal blood pressure for adults is below 120/80 mm Hg. This increase could indicate worsening heart failure, which requires further action.
Choice D rationale:
The client’s weight increased from 80 kg to 82.1 kg. Rapid weight gain may be a sign of fluid retention, a common symptom of heart failure. This requires further action.
Choice E rationale:
The client’s urine output decreased from 480 mL/8 hr to 320 mL/8 hr.However it is still above 30ml/hr signifying normal renal function
Choice F rationale:
On Day 4, the client’s breath sounds were scattered, and crackles were heard bilaterally. This could indicate fluid accumulation in the lungs, a common symptom of heart failure. This requires further action.
So, the correct answer is Choices B, C, D, and F, after analyzing all choices.
Correct Answer is B
Explanation
Choice A rationale:
A patient who had a myocardial infarction (MI) 4 days ago and is anxious about today’s planned discharge would need reassurance and education, but it’s not an immediate concern.
Choice B rationale:
A patient with unstable angina who has just returned after a percutaneous coronary intervention (PCI) is at risk for hemorrhage from the arterial access site. Immediate assessment of blood pressure, pulses, and the access site is required.
Choice C rationale:
A patient with variant angina who is scheduled to receive nifedipine (Procardia) would need monitoring, but it’s not the most urgent.
Choice D rationale:
A patient with pericarditis complaining of sharp, stabbing chest pain would need evaluation, but the risk of complications is less immediate than for Choice B1.
So, the correct answer is B, after analyzing all choices.
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