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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:

A brief episode of ventricular tachycardia, or a rapid heart rate, can occur in patients receiving thrombolytic therapy. However, it is not typically a reason to stop the drug infusion.

Choice B rationale:

Bleeding from the gums can be a sign of excessive bleeding, which is a major risk of thrombolytic therapy. This would be a reason to stop the drug infusion.

Choice C rationale:

A decreased level of consciousness can have many causes and is not specifically associated with thrombolytic therapy.

Choice D rationale:

An increase in blood pressure is not typically a reason to stop thrombolytic therapy.

So, the correct answer is B, after analyzing all choices.

A. Check the electrocardiogram (ECG) for ST segment changes. B. Assess for the presence of jugular venous distention (VD). C. Monitor for changes in the patient's sedimentation rate. D. Assess for the presence of a paradoxical pulse.

Correct Answer is B

Explanation

Choice A rationale:

ST segment changes on an ECG are not typically associated with chronic constrictive pericarditis.

Choice B rationale:

Jugular venous distention (JVD) is a common sign of chronic constrictive pericarditis. If JVD is not present, it may indicate that the therapies are effective.

Choice C rationale:

While the sedimentation rate can indicate inflammation, it is not specific to chronic constrictive pericarditis.

Choice D rationale:

The presence of a paradoxical pulse is not typically associated with chronic constrictive pericarditis.

So, the correct answer is B, after analyzing all choices.

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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?.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is administering a thrombolytic agent to a patient having an acute myocardial infarction. Which patient data indicates that the nurse should stop the drug infusion?.

Correct Answer is B

Explanation

Which action by the nurse will determine if therapies ordered for a patient with chronic constrictive pericarditis are effective?

Correct Answer is B

Explanation

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