After receiving change-of-shift report about the following four clients, which client should the nurse assess first?
56-year-old client with chronic stable angina who is due to receive a dose of nifedipine.
59-year-old with unstable angina who has just returned to the unit after having a heart catheterization with balloon angioplasty.
65-year-old who had a myocardial infarction (MI) 4days ago and is anxious about the planned discharge.
Client who is post coronary artery bypass, with potassium 4.2 mEq/L.
The Correct Answer is B
A. A stable client with chronic angina is not in immediate danger, and the scheduled dose of nifedipine is not an urgent priority.
B. The client with unstable angina who has just undergone a heart catheterization with balloon angioplasty requires immediate assessment for complications such as bleeding, clot formation, or re-occlusion of the artery.
C. The 65-year-old post-MI client is stable, and while their anxiety is important to address, it is not an immediate concern compared to other clients.
D. The client post-coronary artery bypass with a potassium level of 4.2 mEq/L is stable and does not require urgent intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. S1: S1 is the first heart sound, heard at the beginning of systole, and is not related to diastolic dysfunction.
B. S4: This is the correct answer. An S4 sound is heard late in diastole, often due to increased resistance to filling during diastole, which is typical in diastolic dysfunction.
C. S3: An S3 is a low-pitched sound heard early in diastole, typically associated with systolic dysfunction or heart failure with reduced ejection fraction.
D. S2: S2 is the second heart sound, heard during the end of systole and is not associated with diastolic dysfunction.
Correct Answer is C
Explanation
A. Serum insulin levels reflects short-term insulin secretion but does not indicate long-term glucose control.
B. Hemoglobin levels relate to anemia, not glucose control.
C. Hemoglobin A1C level reflects the average blood glucose over the past 2-3 months, providing an excellent measure of long-term control.
D. Fingerstick fasting blood glucose level reflects glucose levels at the moment of testing, not long-term control.
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