After receiving a change-of-shift report about the following four patients on the cardiac care unit, which patient would the nurse assess first?.

A nurse is caring for a client who has heart failure.

Nurses' Notes.

Day 1: Vital Signs.

Bilateral breath sounds clear and present throughout.

Weight 80 kg (176 lb). Urine output 480 mL/8 hr. Day 4: Breath sounds scattered, crackles heard bilaterally.

Apical heart rate rapid and irregular.

Audible S3 gallop.

Weight 82.1 kg (181 lb). Urine output 320 mL/8 hr. Vital Signs.

Day 1: Temperature 37.6° C (99.7° F). Blood pressure 108/50 mm Hg. Pulse 98/min.

Respiratory rate 20/min.

Pulse oximetry 95% on room air.

Day 4: Temperature 36.8° C (98.2° F). Blood pressure 138/80 mm Hg. Pulse 112/min.

Respiratory rate 28/min.

Pulse oximetry 88% on room air.

A nurse is reviewing the assessment findings for the client on day 4. Which of the following findings requires further action? (Select all that apply.).

The nurse obtains a health history from an older adult with a prosthetic mitral valve who has symptoms of infective endocarditis (IE). Which question by the nurse helps identify a risk factor for IE?.

After receiving a change-of-shift report on four patients, which patient would the nurse assess first?.

The nurse is providing teaching about the patient's laboratory values that increase the risk for coronary artery disease (CAD). Which of the following values should the nurse prioritize?.

A nurse is caring for an adolescent in an emergency department.

Vital Signs.

2300: Medical History.

Blood pressure 120/78 mm Hg. Apical pulse rate 100/min.

Respiratory rate 20/min.

2400: Temperature 37.9° C (100.2° F). Oxygen saturation 98% on room air.

Nurses' Notes.

Blood pressure 112/64 mm Hg. Apical pulse rate 108/min.

Respiratory rate 28/min.

Temperature 38.9° C (102° F). Oxygen saturation 95% on room air.

Medical History.

History of rheumatic fever with resulting cardiac valve damage.

Nurses' Notes.

2300: Adolescent brought to emergency department by their parent.

Adolescent reports intermittent low-grade fever and anorexia.

Manifestations presented a few days after having dental work performed.

Now they are worse.

Adolescent noticed shortness of breath with exertion today.

Adolescent in semi-reclining position.

Respirations easy and unlabored while at rest.

Mild dyspnea observed when adolescent ambulated to the room.

Lung sounds clear bilaterally.

Oral mucous membranes pink with petechiae noted.

Adolescent reports diffuse joint pain as 2 on a scale of 0 to 10. 2400: Adolescent restless and sweating, sitting in high-Fowler's position.

Dyspnea noted at rest.

Adolescent reports pain in mid-chest as dull, aching, and as 2 on a scale of 0 to 10. Few coarse rales auscultated bilaterally.

The nurse reports the 2400 assessment findings to the provider.

Which of the following should the nurse anticipate the provider will prescribe? For each potential provider's prescription, specify if the potential prescription is anticipated or contraindicated for the client.

The nurse is admitting a patient who has chest pain. Which assessment data suggest that the pain may be from an acute myocardial infarction?.

A patient who has had chest pain for several hours is admitted with a diagnosis of rule out acute myocardial infarction (AMI). Which laboratory test is most specific for the nurse to monitor in determining whether the patient has had an AMI?.

A nurse on a cardiac care unit is caring for a preschooler.

Nurses' Notes.

Hospital Day 1. 1738: Received 4-year-old child with an exacerbation of heart failure.

Family reports history of congenital mitral stenosis.

Breath sounds with wheezing noted in bilateral lower lobes.

Nonproductive cough noted.

Dyspnea with respiratory rate 30/min.

Oxygen at 2 L/min applied per nasal cannula.

Telemetry applied: Sinus rhythm at rate 116/min.

Abdomen soft, nontender.

Bowel sounds positive all 4 quadrants.

Lower extremities with 2+ edema noted.

Pedal pulses palpable bilaterally.

Peripheral saline lock intact to right forearm with no signs and symptoms of infection.

Weight 20 kg (44 lb). 2015: Increase in dyspnea noted with orthopnea.

Nasal flaring with respiratory rate of 36/min.

Lung sounds with wheezing noted throughout.

Lower extremity edema 3+ to bilateral lower extremities.

Extremities cool with decreased skin pigmentation noted.

Peripheral pulses weak bilateral.

Jugular vein distention noted.

Provider notified.

Received prescription for additional dose of IV furosemide.

Medication Administration Record.

Hospital Day 1: Furosemide 40 mg IV every 6 hr. Administered at 1755.

Give digoxin 250 mcg IV now.

Administered at 1800.

Hospital Day 2: Give digoxin 125 mcg 12 hr after initial dose.

Administered at 0608.

Give digoxin 125 mcg 12 hr after second dose.

Administered at 1804.

Furosemide 10 mg IV now.

Administered at 2020.

Vital Signs.

Hospital Day 1. 1738: Temperature: 36.7°C (98.0°F). Pulse rate: 114/min.

Respiratory rate: 30/min.

Blood pressure: 92/65 mm Hg. Oxygen saturation: 90%. 2015: Temperature: 36.9°C (98.4°F). Pulse rate: 120/min.

Respiratory rate: 36/min.

Blood pressure: 86/54 mmHg.

Oxygen saturation: 86% room air.
select words from the choices below to fill in each blank in the following sentence. The client is at risk for developing Target 1? and Target 2?.

The nurse is assessing a patient with myocarditis before giving a scheduled dose of digoxin (Lanoxin). Which finding is most important for the nurse to communicate to the health care provider?.

A patient who has just been admitted with pulmonary edema is scheduled to receive the following medications. Which medication would the nurse question before giving?.