At the start of an evening shift on a cardiac unit, a licensed practical nurse brings the nurse a list of client reports. Which of the following client reports should the nurse assess first?
Constipation
Indigestion
Swollen ankles
Urinary frequency
None
None
The Correct Answer is B
A. Constipation: While constipation can be uncomfortable, it is not typically considered an immediate threat to a patient's health in a cardiac unit setting. It requires assessment and intervention but is not the highest priority.
B. Indigestion can be a subtle symptom of myocardial infarction (MI) or acute coronary syndrome (ACS), particularly in older adults, women, or clients with diabetes. Clients experiencing "indigestion" may be describing chest discomfort, which requires immediate assessment to rule out a cardiac event. Early identification and intervention for cardiac symptoms are critical to prevent further complications.
C. Swollen ankles can indicate fluid retention, which is a common sign of heart failure. While this symptom requires attention, it does not typically indicate an immediate life-threatening issue compared to potential cardiac ischemia associated with "indigestion."
D. Urinary frequency: This could be related to medications or other conditions. While it should be addressed, it is not the most critical issue compared to potential acute cardiac symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. 3hr oral glucose tolerance test - This test is typically used for diagnosing gestational diabetes or impaired glucose tolerance, not for long-term management.
B. HbA1c - Hemoglobin A1c reflects the average blood glucose levels over the past 2-3 months and is a reliable indicator of long-term glycemic control.
C. Fasting blood glucose test - This provides a snapshot of blood glucose levels at a specific point in time and is not as reliable for assessing long-term glycemic control as HbA1c.
D. Urinalysis for ketones - Urinalysis for ketones is useful for detecting acute complications such as diabetic ketoacidosis but does not reflect long-term management of blood glucose levels.
Correct Answer is B
Explanation
A. The wall suction setting does not directly indicate the functioning of the NG tube.
B. Greenish-yellow drainage fluid may indicate the presence of bile in the stomach, suggesting
that the NG tube is not adequately draining gastric contents, which could indicate a malfunction.
C. An aspirate pH of 3 indicates gastric acidity, which is expected in the stomach and does not necessarily indicate a problem with NG tube function.
D. Abdominal rigidity may suggest intra-abdominal pathology but does not specifically indicate NG tube dysfunction.
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