An adult male is admitted with dyspnea on exertion, persistent cough, and palpitations. His telemetry reveals atrial fibrillation. Which additional assessment finding warrants the most immediate intervention by the nurse?
Respiratory rate of 22 breaths/minute.
Production of frothy, pink-tinged secretions.
Pitting edema of the ankles bilaterally.
Irregular apical heart rhythm.
The Correct Answer is B
A. Respiratory rate of 22 breaths/minute: This rate is mildly elevated and may reflect exertional dyspnea or anxiety, but it does not indicate immediate respiratory distress. It requires monitoring but does not demand urgent intervention.
B. Production of frothy, pink-tinged secretions: This finding is a hallmark of acute pulmonary edema and signals severe left-sided heart failure with fluid backing up into the alveoli. It compromises oxygenation and requires urgent intervention, such as diuretics and supplemental oxygen.
C. Pitting edema of the ankles bilaterally: Pitting edema reflects chronic volume overload, often associated with right-sided heart failure. While concerning, it develops over time and is not as immediately life-threatening as pulmonary congestion with compromised gas exchange.
D. Irregular apical heart rhythm: An irregular rhythm is consistent with atrial fibrillation and explains the palpitations, but it is a known condition in this case. Unless accompanied by hemodynamic instability, it does not demand immediate intervention on its own.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Begin chest compressions at a depth of at least 2 in (5.1 cm): Initiating high-quality chest compressions immediately is the priority in a pulseless and non-breathing client. This promotes circulation of oxygenated blood to vital organs, and improves chances of survival until defibrillation or advanced care is available.
B. Perform forceful sternal rub to check for unresponsiveness: A sternal rub is used to assess responsiveness, but it is unnecessary once the client is confirmed to be unresponsive, pulseless, and not breathing. Delaying compressions could reduce survival chances.
C. Assess the client for any obvious injuries due to the sudden fall: While it is important to note injuries, it is not the immediate priority in a client without a pulse or respirations. Life-saving measures such as CPR should take precedence over secondary assessments.
D. Remove the client's clothes and apply automated external defibrillator (AED) pads to chest: Applying the AED is a critical step but should follow the immediate initiation of chest compressions. If another responder is present, tasks can be divided, but CPR should not be delayed for AED pad placement.
Correct Answer is A
Explanation
A. A description of the chest pain when client is at rest: Determining whether the pain occurs at rest helps differentiate stable from unstable angina. Stable angina typically resolves with rest and is exertion-related, while pain at rest may suggest unstable angina.
B. A demonstration of the activity that precipitates pain: While understanding what provokes the pain is helpful, a physical demonstration is unnecessary and potentially dangerous, especially if it might trigger another anginal episode.
C. A complete seven (7) day diet history of client's oral intake: Dietary intake is not immediately relevant for evaluating recent angina symptoms. Priority should be placed on identifying acute features that may signal unstable angina or myocardial infarction.
D. The client’s blood pressures sitting and standing: Assessing for orthostatic hypotension is useful in evaluating dizziness or syncope but does not directly address the nature or severity of chest pain. It is not the priority assessment for symptoms of angina pectoris following exertion.
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