After receiving a change-of-shift report, which patient admitted to the emergency department should the nurse assess first?
A 39-year-old patient who has right calf tenderness and swelling after a plane ride
A 58-year-old patient taking anticoagulants for atrial fibrillation who has black stools
A 67-year-old patient who has a gangrenous foot ulcer with a weak pedal pulse
A 50-year-old patient who is reporting sudden sharp and severe upper back pain .
The Correct Answer is D
Choice A rationale
While calf tenderness and swelling after a plane ride could potentially indicate a deep vein thrombosis, this condition is not immediately life-threatening in most cases. The patient would need evaluation and treatment, but other patients might have more urgent needs14.
Choice B rationale
A patient taking anticoagulants for atrial fibrillation who has black stools could potentially have gastrointestinal bleeding, which would need evaluation. However, this condition might not be immediately life-threatening, and other patients might have more urgent needs14.
Choice C rationale
A patient with a gangrenous foot ulcer and a weak pedal pulse would need evaluation and treatment. However, this condition might not be immediately life-threatening, and other patients might have more urgent needs14.
Choice D rationale
A patient reporting sudden sharp and severe upper back pain could potentially have an aortic dissection, which is a life-threatening condition that requires immediate evaluation and treatment. Therefore, this patient should be assessed first14.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Encouraging exercise to increase heart rate in a patient with myocardial ischemia could potentially worsen the condition. Exercise increases the demand for oxygen in the heart, which may not be met due to the reduced blood flow in ischemia, potentially leading to further damage.
Choice B rationale
Administering a diuretic to decrease volume is not the most beneficial intervention for a patient with myocardial ischemia. While diuretics can reduce the workload of the heart by decreasing blood volume, they do not directly address the issue of reduced blood flow to the heart muscle that characterizes ischemia.
Choice C rationale
Giving an antibiotic to decrease infection is not relevant in this context. Myocardial ischemia is not caused by an infection, but by a reduction in blood flow to the heart muscle, often due to a blockage in one or more of the coronary arteries.
Choice D rationale
Applying oxygen to increase myocardial oxygen supply is the most beneficial intervention for a patient with myocardial ischemia. Oxygen therapy can help to meet the oxygen demand of the heart muscle when blood flow is reduced, alleviating symptoms and preventing further damage.
Correct Answer is ["B","C","D","E"]
Explanation
Choice A rationale
Promoting a diet high in saturated fats is not a recommended strategy for preventing cardiovascular disease. Saturated fats can raise the level of cholesterol in your blood and increase your risk of heart disease and stroke.
Choice B rationale
Advising smoking cessation is a crucial intervention in preventing cardiovascular disease. Chemicals in tobacco can damage the heart and blood vessels, leading to narrowing of the arteries (atherosclerosis). Atherosclerosis can ultimately lead to a heart attack.
Choice C rationale
Regular blood pressure monitoring is important because high blood pressure is a significant risk factor for heart disease. It can cause the arteries that supply blood to your heart muscle to harden and narrow, leading to a heart attack.
Choice D rationale
Regular cholesterol screenings are essential because high levels of cholesterol can lead to the buildup of plaques in your arteries, increasing your risk of heart disease.
Choice E rationale
Encouraging regular physical exercise is a key strategy in preventing cardiovascular disease. Regular exercise helps control your weight and reduce your chances of developing other conditions that may put a strain on your heart, such as high blood pressure, high cholesterol, and diabetes.
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