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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Troponin I: Troponin I is a highly specific marker for myocardial injury. Elevated levels suggest acute coronary syndrome or myocardial infarction, which could explain the client’s chest pain, shortness of breath, and syncope. This findings may indicate potential for life-threatening cardiac damage.

B. Blood glucose: Abnormal glucose levels can contribute to long-term cardiovascular risk and may affect recovery, but they are not the priority in the acute setting unless critically low or high. They do not explain the acute onset of chest symptoms and syncope.

C. Oxygen saturation: While oxygen saturation is important, it is typically monitored continuously or via spot checks. Unless critically low, a slight reduction in oxygen saturation would not be as urgent as a positive cardiac biomarker in this clinical context.

D. Hematocrit: A low hematocrit could indicate anemia, which might contribute to fatigue or dyspnea, but it is not as immediately concerning as cardiac ischemia in a client with chest pain and syncope. It is a secondary concern in this case.

A. Bilateral tinnitus when initially standing up. B. Dizziness when rising from the bedside. C. Hypotension with a systolic of 90 mm Hg. D. Onset of headache after administration.

Correct Answer is C

Explanation

A. Bilateral tinnitus when initially standing up: Tinnitus is not a common or serious adverse effect of nitroglycerin. While it may indicate another underlying issue, such as hypertension or ototoxicity, it is not immediately life-threatening.

B. Dizziness when rising from the bedside: Dizziness can result from the vasodilatory effects of nitroglycerin causing orthostatic hypotension. It is relatively common and usually managed with safety precautions and monitoring rather than immediate reporting.

C. Hypotension with a systolic of 90 mm Hg: A systolic blood pressure of 90 mm Hg is concerning after nitroglycerin administration, as the drug significantly lowers preload and can precipitate hemodynamic instability. This finding requires prompt HCP notification to prevent complications such as syncope or myocardial underperfusion.

D. Onset of headache after administration: Headache is a well-known and expected side effect of nitroglycerin due to cerebral vasodilation. While uncomfortable, it is generally benign and does not warrant immediate reporting unless it becomes severe or unrelenting.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

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