After receiving the shift change report about four patients in the cardiac care unit, which patient should the nurse prioritize for assessment?
A 59-year-old patient with unstable angina who has just returned from a percutaneous coronary intervention (PCI).
A 56-year-old patient with variant angina due to receive nifedipine (Procardia).
A 65-year-old patient who had a myocardial infarction (MI) 4 days ago and is anxious about discharge planned for today.
A 39-year-old patient with pericarditis complaining of sharp, stabbing chest pain.
The Correct Answer is A
Choice A rationale
A 59-year-old patient with unstable angina who has just returned from a percutaneous coronary intervention (PCI) should be prioritized for assessment. PCI is a procedure to open blocked or narrowed coronary arteries and can lead to complications such as re-occlusion of the artery or bleeding from the catheter insertion site. Furthermore, unstable angina is a condition that can progress to myocardial infarction if not managed effectively.
Choice B rationale
A 56-year-old patient with variant angina due to receive nifedipine (Procardia) requires monitoring, but is not the highest priority. Variant angina is a form of angina that occurs at rest, often with severe pain, but it is usually well-controlled with medications like nifedipine.
Choice C rationale
A 65-year-old patient who had a myocardial infarction (MI) 4 days ago and is anxious about discharge planned for today is a lower priority for assessment. While it’s important to address the patient’s anxiety and provide education about post-discharge care, this patient is not in immediate danger.
Choice D rationale
A 39-year-old patient with pericarditis complaining of sharp, stabbing chest pain requires assessment, but is not the highest priority. Pericarditis is inflammation of the pericardium, the sac-like covering of the heart, and while it can cause severe pain, it is not typically life- threatening.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Sinus tachycardia is a regular, rapid heart rate caused by rapid firing of the sinoatrial node. It is characterized by a heart rate of greater than 100 beats per minute, and P waves are present before each QRS complex. This does not match the description given.
Choice B rationale
Ventricular tachycardia is a fast, regular beating of the ventricles that may last for only a few seconds or for much longer. In this condition, the ventricular rate is often between 120 and 200 beats per minute, and P waves are not associated with the QRS complexes. This matches the description given.
Choice C rationale
Ventricular fibrillation is a severe condition in which the heart beats with rapid, erratic electrical impulses. This causes the ventricles to quiver uselessly instead of pumping blood. The description does not match this condition.
Choice D rationale
Atrial flutter is a condition that shares similarities with atrial fibrillation, both involve an irregular heartbeat. However, atrial flutter is more organized and less chaotic than atrial fibrillation, which can make it more manageable. The description does not match this condition.
Correct Answer is B
Explanation
Choice A rationale
A pleural friction rub, which is a grating sound caused by the inflammation of the pleural surfaces during respiration, is not typically associated with cardiac tamponade. It is more commonly associated with conditions affecting the lungs, such as pneumonia or pleurisy.
Choice B rationale
Distended neck veins are a classic sign of cardiac tamponade. This occurs due to increased pressure in the right atrium as a result of the impaired filling of the ventricles. This is a critical sign that should be reported immediately.
Choice C rationale
Widening pulse pressure (an increase in the difference between systolic and diastolic blood pressure) is not typically associated with cardiac tamponade. In fact, cardiac tamponade more commonly presents with a narrowed pulse pressure.
Choice D rationale
Bradycardia, or a slow heart rate, is not typically a sign of cardiac tamponade. More commonly, tachycardia, or a fast heart rate, is observed in response to decreased cardiac output.
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