A patient with a recent exacerbation of heart failure is feeling uncomfortable and anxious, with a sensation of flopping in the chest.
While waiting for an electrocardiogram (ECG), which assessment should the nurse prioritize?

Rhythm of the apical pulse.

Volume of pedal pulses.

Degree of skin elasticity.

Length of capillary refill.

Answer and Explanation

The Correct Answer is A

Choice A rationale

In a patient with a recent exacerbation of heart failure who is feeling uncomfortable and anxious, with a sensation of flopping in the chest, the rhythm of the apical pulse should be prioritized. This is because changes in heart rhythm can indicate worsening heart failure or other serious cardiac conditions.

Choice B rationale

While the volume of pedal pulses can provide information about peripheral circulation, it is not as immediately relevant as the rhythm of the apical pulse in a patient with heart failure experiencing discomfort and anxiety.

Choice C rationale

The degree of skin elasticity can provide information about hydration status, but it is not as immediately relevant as the rhythm of the apical pulse in a patient with heart failure experiencing discomfort and anxiety.

Choice D rationale

The length of capillary refill can provide information about peripheral circulation and overall cardiovascular status, but it is not as immediately relevant as the rhythm of the apical pulse in a patient with heart failure experiencing discomfort and anxiety.

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Correct Answer is C

Explanation

Choice A rationale

While a headache with sudden onset can be a symptom of various conditions, it is not the most critical finding to report in a client with atrial fibrillation and a rapid ventricular rate.

Choice B rationale

Flat jugular vein distention (JVD) at 45 degrees is not the most critical finding to report in a client with atrial fibrillation and a rapid ventricular rate.

Choice C rationale

An abnormal level of consciousness can be a sign of decreased cerebral perfusion, which can occur in a client with atrial fibrillation and a rapid ventricular rate. This is a critical finding that should be reported to the healthcare provider immediately.

Choice D rationale

Nausea with vomiting is not the most critical finding to report in a client with atrial fibrillation and a rapid ventricular rate.

A. Respiratory rate. B. Pain scale. C. Blood pressure. D. Level of consciousness.

Correct Answer is B

Explanation

Choice A rationale

While monitoring the respiratory rate is important in a patient receiving opioids like hydromorphone, it does not directly indicate whether the patient is receiving an equianalgesic dose of the medication.

Choice B rationale

Pain scale assessment is the most direct way to evaluate if the patient is receiving an equianalgesic dose of hydromorphone. Equianalgesic refers to a dose of one opioid that would provide the same level of pain relief as a given dose of another opioid. If the patient’s pain is well-controlled, it suggests that the dose of hydromorphone is equianalgesic to the dose of the previous opioid.

Choice C rationale

Monitoring blood pressure is important in a patient receiving opioids as these medications can cause hypotension. However, blood pressure does not directly indicate whether the patient is receiving an equianalgesic dose of hydromorphone.

Choice D rationale

While it’s important to monitor the level of consciousness in a patient receiving opioids as these medications can cause sedation, it does not directly indicate whether the patient is receiving an equianalgesic dose of hydromorphone.

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A patient with a recent exacerbation of heart failure is feeling uncomfortable and anxious, with a sensation of flopping in the chest.While waiting for an electrocardiogram (ECG), which assessment should the nurse prioritize?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has developed atrial fibrillation with a ventricular rate of 150 beats/minute observed via telemetry.The client’s blood pressure is 80/40 mm Hg. Which finding is most important for the nurse to report to the healthcare provider?

Correct Answer is C

Explanation

A patient with metastatic cancer who was taking hydromorphone orally at home is now receiving the medication intravenously while in the hospital.To evaluate if the patient is receiving an equianalgesic dose of the hydromorphone, which assessment should the nurse complete?

Correct Answer is B

Explanation

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A patient with a recent exacerbation of heart failure is feeling uncomfortable and anxious, with a sensation of flopping in the chest.
While waiting for an electrocardiogram (ECG), which assessment should the nurse prioritize?