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.

Answer and Explanation

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.

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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.

A. Teach the patient to take deep, slow breaths to control the pain. B. Place the patient in Fowler's position, leaning forward on the table. C. Force fluids to 3000 mL/day to decrease the inflammation. D. Provide a fresh ice bag every hour for the patient to place on the chest.

Correct Answer is B

Explanation

Choice A rationale:

Teaching the patient to take deep, slow breaths might not be effective in controlling the pain due to acute pericarditis.

Choice B rationale:

Placing the patient in Fowler’s position, leaning forward on the table, can help relieve the pain associated with acute pericarditis.

Choice C rationale:

Forcing fluids to 3000 mL/day to decrease inflammation is not a recommended action for managing pain due to acute pericarditis.

Choice D rationale:

Providing a fresh ice bag every hour for the patient to place on the chest is not a recommended action for managing pain due to acute pericarditis.

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

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","C","D","F"]

Explanation

A patient has pain due to acute pericarditis. Which action would the nurse take?.

Correct Answer is B

Explanation

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