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 A
Explanation
Choice A rationale
Bleeding from the gums is a sign of excessive bleeding, which can be a side effect of thrombolytic therapy. Thrombolytic agents work by dissolving blood clots, but they can also interfere with the body’s normal clotting mechanism, leading to bleeding. If a patient experiences unusual or excessive bleeding, it may be necessary to stop the infusion of the thrombolytic agent.
Choice B rationale
An increase in blood pressure is not typically a reason to stop the infusion of a thrombolytic agent in a patient with an acute myocardial infarction. While blood pressure should be monitored closely during thrombolytic therapy, an increase in blood pressure is not a common side effect.
Choice C rationale
A nonsustained episode of ventricular tachycardia is not typically a reason to stop the infusion of a thrombolytic agent in a patient with an acute myocardial infarction. While arrhythmias can occur during a myocardial infarction, they are not a common side effect of thrombolytic therapy.
Choice D rationale
A decreased level of consciousness can be a sign of many serious conditions, including bleeding in the brain. However, it is not typically a reason to stop the infusion of a thrombolytic agent unless it is accompanied by other signs of excessive bleeding.
Correct Answer is D
Explanation
Choice A rationale
High-output heart failure is not typically associated with chronic pulmonary disease and elevated pulmonary vascular resistance. High-output heart failure occurs when the heart is unable to meet the body’s increased demand for blood flow, which is not the case in this scenario.
Choice B rationale
Low-output heart failure is also not typically associated with chronic pulmonary disease and elevated pulmonary vascular resistance. Low-output heart failure occurs when the heart is unable to pump enough blood to meet the body’s needs, which is not the case in this scenario.
Choice C rationale
Left heart failure is not typically associated with chronic pulmonary disease and elevated pulmonary vascular resistance. Left heart failure occurs when the left side of the heart is unable to pump enough blood to the body, which is not the case in this scenario.
Choice D rationale
Right heart failure is the correct answer. In the context of a 65-year-old male patient diagnosed with chronic pulmonary disease and elevated pulmonary vascular resistance, the nurse should assess for right heart failure. This is because the right side of the heart pumps blood to the lungs, and if the pulmonary vascular resistance is elevated, it can put strain on the right side of the heart, leading to right heart failure.
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