After the shift change, which patient in the emergency department should the nurse prioritize for assessment?
A 39-year-old patient experiencing tenderness and swelling in the right calf following a flight.
A 58-year-old patient on anticoagulants for atrial fibrillation presenting with black stools.
A 67-year-old patient with a gangrenous foot ulcer and a weak pedal pulse.
A 50-year-old patient reporting sudden, severe upper back pain.
The Correct Answer is B
Choice A rationale
A 39-year-old patient experiencing tenderness and swelling in the right calf following a flight may be experiencing deep vein thrombosis (DVT), a condition that can lead to serious complications such as pulmonary embolism if not treated. However, DVT is not immediately life-threatening in most cases.
Choice B rationale
A 58-year-old patient on anticoagulants for atrial fibrillation presenting with black stools is likely experiencing gastrointestinal bleeding, a common side effect of anticoagulant therapy. This can lead to severe blood loss, anemia, and hypovolemic shock, which can be life-threatening if not promptly addressed. Therefore, this patient should be prioritized for assessment.
Choice C rationale
A 67-year-old patient with a gangrenous foot ulcer and a weak pedal pulse likely has peripheral artery disease and an infection that could lead to sepsis if not treated. However, while this condition needs medical attention, it is not as immediately life-threatening as gastrointestinal bleeding.
Choice D rationale
A 50-year-old patient reporting sudden, severe upper back pain could be experiencing a number of conditions, ranging from musculoskeletal strain to aortic dissection. While an aortic dissection is a medical emergency, without additional symptoms such as chest pain, shortness of breath, or loss of consciousness, this patient is not the highest priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Recurring chest pain can be a symptom of a serious condition such as a heart attack, which can occur if a blood clot forms in a vein deep inside the body, breaks off, and travels to the heart.
This is a potential complication of Deep Vein Thrombosis (DVT) and other vascular issues. Therefore, it’s important for the nurse to inquire about recurring chest pain in a patient with a past history of DVT and other vascular issues.
Choice B rationale
A peptic ulcer is a sore that develops on the lining of the stomach, upper small intestine, or lower esophagus. While peptic ulcers can cause discomfort and other symptoms, they are not typically associated with DVT or other vascular issues. Therefore, while it’s always important for the nurse to have a complete understanding of a patient’s health history, inquiring about a peptic ulcer may not be directly relevant to a patient with a past history of DVT and other vascular issues.
Choice C rationale
An aneurysm is a bulge or ballooning in the wall of an artery. Aneurysms can occur in any artery in the body, and they can be life-threatening if they rupture or dissect (tear)3. While aneurysms can be associated with certain vascular diseases, they are not typically associated with DVT3. Therefore, while it’s important for the nurse to be aware of a patient’s complete health history, inquiring about an aneurysm may not be directly relevant to a patient with a past history of DVT.
Choice D rationale
Rheumatoid arthritis is an autoimmune disease that causes inflammation in the joints. While it can cause a variety of symptoms and complications, it is not typically associated with DVT or other vascular issues. Therefore, while it’s always important for the nurse to have a complete understanding of a patient’s health history, inquiring about rheumatoid arthritis may not be directly relevant to a patient with a past history of DVT and other vascular issues.
Correct Answer is D
Explanation
Choice A rationale
High-output heart failure is not typically associated with chronic pulmonary disease and elevated pulmonary vascular resistance. High-output heart failure occurs when the heart is unable to meet the body’s increased demand for blood flow, which is not the case in this scenario.
Choice B rationale
Low-output heart failure is also not typically associated with chronic pulmonary disease and elevated pulmonary vascular resistance. Low-output heart failure occurs when the heart is unable to pump enough blood to meet the body’s needs, which is not the case in this scenario.
Choice C rationale
Left heart failure is not typically associated with chronic pulmonary disease and elevated pulmonary vascular resistance. Left heart failure occurs when the left side of the heart is unable to pump enough blood to the body, which is not the case in this scenario.
Choice D rationale
Right heart failure is the correct answer. In the context of a 65-year-old male patient diagnosed with chronic pulmonary disease and elevated pulmonary vascular resistance, the nurse should assess for right heart failure. This is because the right side of the heart pumps blood to the lungs, and if the pulmonary vascular resistance is elevated, it can put strain on the right side of the heart, leading to right heart failure.
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