After receiving report on the following clients, which client should the nurse assess first?

Client with infective endocarditis who has a murmur and splinter hemorrhages

Client with rheumatic fever who has sharp chest pain with a deep breath

Client with dilated cardiomyopathy who has bilateral crackles at the lung bases

Client with acute aortic regurgitation whose blood pressure is 86/54 mm Hg

Answer and Explanation

The Correct Answer is D

A. A murmur and splinter hemorrhages are expected findings in infective endocarditis and do not indicate an immediate life-threatening condition.
B. Sharp chest pain with inspiration in rheumatic fever may indicate pericarditis, which needs monitoring but is not immediately unstable.
C. Bilateral crackles suggest fluid overload in dilated cardiomyopathy, requiring attention, but not as urgent as hypotension in acute valve failure.
D. Acute aortic regurgitation with hypotension (BP 86/54 mm Hg) indicates a possible hemodynamic collapse and cardiogenic shock, making this client the highest priority for immediate assessment and intervention.

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Correct Answer is C

Explanation

A. Fluid overload is associated with elevated CVP, not low CVP.
B. Left ventricular failure may eventually cause elevated pulmonary pressures and increased CVP, but a low CVP does not indicate left-sided failure.
C. Hypovolemia (low circulating blood volume) leads to a decreased central venous pressure (CVP) because there is less venous return to the heart. This is the most accurate interpretation of a low CVP reading.
D. An intracardiac shunt may affect circulation dynamics but is not a typical cause of isolated low CVP.

A. Increased respiratory rate B. Hypotension C. Anuria D. Decreased level of consciousness

Correct Answer is A

Explanation

A. Increased respiratory rate – Tachypnea (increased respiratory rate) is often the earliest compensatory sign of shock as the body attempts to correct metabolic acidosis and hypoxia by increasing oxygen intake and carbon dioxide removal.
B. Hypotension – Occurs later in the shock progression, typically when compensatory mechanisms fail.
C. Anuria – Indicates prolonged or severe shock leading to organ failure, not an early finding.
D. Decreased level of consciousness – A later sign, suggesting impaired cerebral perfusion due to worsening shock.

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After receiving report on the following clients, which client should the nurse assess first?

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Naxlex Comprehensive Predictor Exams

A nurse is evaluating the central venous pressure (CVP) of a client who has sustained multiple traumas. Which of the following interpretations of a low CVP pressure should the nurse make?

Correct Answer is C

Explanation

A nurse is caring for a client who is at risk for developing shock. Which of the following findings is the earliest indicator that this complication is occurring?

Correct Answer is A

Explanation

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