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 .

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale
Sexual activity uses about as much energy as climbing two flights of stairs. This comparison can help patients understand that if they can perform activities of similar exertion without chest pain or undue fatigue, it may be safe to resume sexual activity. However, patients should always consult with their healthcare provider before resuming sexual activity after an acute myocardial infarction (AMI).
Choice B rationale
While holding and cuddling are good ways to maintain intimacy after a heart attack, this does not directly address the patient’s question about safely resuming sexual intercourse.
Choice C rationale
While it is true that the doctor will provide sexual guidelines when the patient’s heart is strong enough, this response does not provide the patient with immediate guidance or reassurance.
Choice D rationale
While most patients are able to enjoy intercourse without any complications, this statement may be too general and does not take into account the individual patient’s health status and recovery progress.

A. Assess the need for smoking cessation. B. Apply TED hose to bilateral legs. C. Consult physical therapy. D. Obtain Ankle-Brachial Index (ABI) with a hand-held Doppler.

Correct Answer is B

Explanation

Choice A rationale
Assessing the need for smoking cessation is a standard part of nursing care, especially for patients with circulatory issues. Smoking can exacerbate circulatory problems and delay wound healing.
Choice B rationale
Applying TED hose to bilateral legs might not be appropriate for this patient. TED hose are compression stockings designed to prevent deep vein thrombosis and promote circulation.
However, in a patient with weak pedal pulses and a full-thickness wound on the leg, the compression from the stockings could potentially worsen circulation to the area and impede wound healing.
Choice C rationale
Consulting physical therapy could be beneficial for this patient. Physical therapists can provide exercises and interventions to improve circulation and mobility, which could help with the patient’s circulatory issues and wound healing.
Choice D rationale
Obtaining an Ankle-Brachial Index (ABI) with a hand-held Doppler could be useful in this situation. The ABI is a simple, non-invasive test that can help diagnose peripheral artery disease (PAD), a condition that could be causing the patient’s weak pedal pulses and wound healing issues.

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After receiving a change-of-shift report, which patient admitted to the emergency department should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

For a patient recovering from an acute myocardial infarction (AMI) who inquires about safely resuming sexual intercourse, what would be the best response from the nurse?

Correct Answer is A

Explanation

The nurse is caring for a client with weak pedal pulses, absent hair on bilateral legs, and a full-thickness wound on the right lateral malleolus with defined margins, including a minimal amount of serous exudate. Which of the following interventions is contraindicated?

Correct Answer is B

Explanation

The nurse is conducting a physical assessment on a client with infective endocarditis (IE). The nurse observes flat, reddened, non-tender maculae on the hands and feet. What does the nurse understand these to be?

Which antihypertensive medication is not recommended for patients with chronic obstructive pulmonary disease (COPD) and asthma?

Given the electrocardiogram tracing below for a client who is unresponsive and without a pulse, what should be the nurse’s priority action?

Diltiazem (Cardizem) has been prescribed for a patient newly diagnosed with Prinzmetal’s (variant) angina. What accurate action of diltiazem should the nurse include in the teaching plan?

When teaching clients in a community-based setting strategies for preventing cardiovascular disease, which interventions should the nurse include?

A 56-year-old individual visits his primary care provider for a routine checkup.The physical examination reveals edema, an enlarged liver (hepatomegaly), and muffled heart sounds. Which of the following findings should the nurse be most concerned about?

Which patient statement indicates that the nurse’s teaching about sublingual nitroglycerin (Nitrostat) has been effective?

What should a nurse inquire about from a patient with a past history of Deep Vein Thrombosis (DVT) and other vascular issues?