After receiving a change-of-shift report on four patients, which patient would the nurse assess first?.
Patient with dilated cardiomyopathy who has bilateral crackles at the lung bases.
Patient with acute aortic regurgitation whose blood pressure is 86/54 mm Hg.
Patient with infective endocarditis who has a murmur and splinter hemorrhages.
Patient with rheumatic fever who has sharp chest pain with a deep breath.
The Correct Answer is B
Choice A rationale:
While bilateral crackles at the lung bases indicate fluid accumulation, a common symptom of dilated cardiomyopathy, it’s not as immediately life-threatening as some other conditions.
Choice B rationale:
Acute aortic regurgitation can lead to a rapid and severe drop in blood pressure, which is a medical emergency. Therefore, this patient should be assessed first.
Choice C rationale:
While a murmur and splinter hemorrhages are symptoms of infective endocarditis, they are not as immediately life-threatening as acute aortic regurgitation.
Choice D rationale:
Sharp chest pain with a deep breath could be a symptom of rheumatic fever, but it’s not as immediately life-threatening as acute aortic regurgitation.
So, the correct answer is Choice B, after analyzing all choices.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
This is correct. Standing still for prolonged periods can cause blood to pool in the legs, increasing blood pressure.
Choice B rationale:
This is also correct. Stopping the medication abruptly can cause a rebound increase in blood pressure.
Choice C rationale:
This is incorrect. Furosemide is a diuretic that can cause the body to lose potassium, so it’s important to consume potassium-rich foods.
Choice D rationale:
This is correct. Furosemide can cause orthostatic hypotension, a form of low blood pressure that happens when you stand up from sitting or lying down.
So, the correct answer is Choice C, 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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