After receiving shift change report, which of the following patients should the nurse see first?

Patient with history of mitral valve prolapse

Patient post op endovascular graft procedure for a 5.7cm abdominal aortic aneurysm with a urine output of 35mL/hr

Patient with infecting endocarditis having new onset flank pain and hematuria

Patient awaiting discharge after pacemaker surgery 2 days ago

Answer and Explanation

The Correct Answer is C

A.   While mitral valve prolapse requires ongoing monitoring, it is not a critical or immediately life- threatening condition.
B.   A urine output of 35 mL/hr is slightly low but not critically concerning. This patient can be monitored closely and interventions can be implemented if necessary, but they do not require immediate attention.
C.   New-onset flank pain and hematuria in a patient with infective endocarditis suggest a potential complication, such as renal infarction or abscess. These conditions can be life-threatening and require prompt intervention.
D.   While this patient requires ongoing monitoring, they are not in a critical condition and can be seen after addressing the patient with infective endocarditis.

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Correct Answer is C

Explanation

A. Occasional hiccups are not a common side effect of having a pacemaker. However, some patients may experience hiccups if the pacemaker’s lead irritates the diaphragm or other nearby structures. While hiccups are not a primary concern, they are not a standard expectation for all patients.
B. There is no need to disconnect a garage door opener due to having a pacemaker. Modern pacemakers are designed to be shielded from interference caused by common household electronic devices. The statement indicates a misunderstanding of the precautions necessary for managing a pacemaker.
C. This statement indicates a correct understanding of pacemaker care. It is important for patients with pacemakers to inform airport security screeners about their device before going through metal detectors or body scanners.
D. Regular monitoring of the pulse is important for patients with pacemakers, but taking the pulse every 3-4 days may not be necessary unless specifically advised by the healthcare provider. Typically, patients are instructed to monitor their pulse more frequently if they experience symptoms such as dizziness, fainting, or irregular heartbeats.

A. Administer digoxin B. Continue to monitor the client. C. Defibrillate the client. D. Prepare for transcutaneous pacing

Correct Answer is D

Explanation

A. Digoxin is a medication used primarily to treat heart failure and certain types of arrhythmias, such as atrial fibrillation. It works by increasing the force of heart contractions and slowing the heart rate. However, digoxin is not typically used to treat bradycardia and may actually exacerbate the condition by further slowing the heart rate.
B. While monitoring is an essential part of patient care, it is not sufficient alone in this situation. The client’s heart rate is very low (45 beats per minute) and their blood pressure is low (82/60 mm Hg), which suggests they are symptomatic and potentially unstable.
C. Defibrillation is used to treat life-threatening arrhythmias such as ventricular fibrillation or pulseless ventricular tachycardia. It is not used for sinus bradycardia, which is a slow heart rate rather than a rapid, disorganized rhythm requiring electrical shock.

D. Transcutaneous pacing involves applying external pacing pads to the skin to stimulate the heart and increase the heart rate. This is a suitable intervention for symptomatic bradycardia, especially when accompanied by low blood pressure and dizziness.

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After receiving shift change report, which of the following patients should the nurse see first?

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Naxlex Comprehensive Predictor Exams

A nurse is completing discharge teaching with a client who has a permanent pacemaker. Which of the following statements by the client indicates understanding of the teaching?

Correct Answer is C

Explanation

A client in sinus bradycardia, with a heart rate of 45 beats per minute and blood pressure of 82/60 mm Hg, reports dizziness. Which intervention should the nurse anticipate will be prescribed?

Correct Answer is D

Explanation

A patient admitted with diagnosis of pericarditis develops hypotension, shortness of breath, tachycardia, distended neck veins. Which of the following procedures with the nurse anticipate assisting for this emergent situation?

A nurse is planning care for a client who has suspected cardiac tamponade. Which of the following diagnostic tests should the nurse anticipate the provider to order first?

After receiving shift change report, which of the following patients should the nurse see first?

The nurse obtains a health history from an older adult with a prosthetic mitral valve who has symptoms of infective endocarditis (IE). Which question by the nurse helps identify a risk factor for IE?

A nurse is caring for a client in the emergency department Exhibits Which of the following interventions should the nurse expect when planning care for this client? (Select All that Apply)

A patient with a sinus node dysfunction has a permanent pacemaker inserted. Before discharge, what should the nurse include when teaching the patient?

Which of the following are risk factors for abdominal aortic aneurysm (AAA)? (Select all that apply.)

A patient has been diagnosed with a 4cm abdominal aortic aneurysm. Which of the following conditions would indicate surgical intervention may be necessary?