The night nurse in the cardiac ICU has just received a report on several patients. Which of the following clients should the nurse prioritize for rounds?

A patient with a new-onset of confusion and restlessness.

A patient who reports dizziness after receiving captopril (Capoten).

A patient who requires oxygen via nasal cannula with saturations of 97%.

A patient who has received digoxin and has a blood pressure (BP) of 100/56.

Answer and Explanation

The Correct Answer is A

Choice A reason: A patient with a new-onset of confusion and restlessness is a priority because these symptoms could indicate a serious condition such as hypoxia, electrolyte imbalance, or a neurological event like a stroke. These changes in mental status need to be evaluated immediately to prevent further complications.

Choice B reason: Dizziness after receiving captopril (Capoten) can be a side effect of the medication due to its blood pressure-lowering effects. While it should be monitored, it is not as urgent as the new-onset confusion and restlessness seen in another patient.

Choice C reason: A patient requiring oxygen via nasal cannula with saturations of 97% is stable as the oxygen saturation is within normal limits. This patient does not need to be prioritized over others with more acute symptoms.

Choice D reason: A patient who has received digoxin and has a blood pressure of 100/56 should be monitored, especially for signs of digoxin toxicity. However, this situation is not as critical as the new-onset confusion and restlessness in another patient.

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Correct Answer is C

Explanation

Choice A reason: Abdominal pain is not a typical complication of hypophysectomy and is less urgent compared to other potential complications.

Choice B reason: Urticaria (hives) of the arms can indicate an allergic reaction but is not directly related to the surgery. It requires attention but is not the most critical finding.

Choice C reason: Persistent nasal drainage following hypophysectomy could indicate a cerebrospinal fluid (CSF) leak, which is a serious complication. CSF leaks require immediate medical attention to prevent meningitis and other complications.

Choice D reason: Pain during urination is not directly related to the hypophysectomy and is less urgent compared to other potential complications.

A. Symmetrical joint pain that is relieved with rest B. Unilateral pain in the weight-bearing joints C. Symmetrical joint pain D. Hypoglycemia

Correct Answer is C

Explanation

Choice A reason: Symmetrical joint pain that is relieved with rest is more characteristic of osteoarthritis, not rheumatoid arthritis. RA typically involves persistent, symmetrical joint pain and inflammation.

Choice B reason: Unilateral pain in the weight-bearing joints is not characteristic of RA. Rheumatoid arthritis generally affects joints symmetrically on both sides of the body.

Choice C reason: Symmetrical joint pain is a hallmark of rheumatoid arthritis. RA causes inflammation and pain in multiple joints, typically affecting the same joints on both sides of the body.

Choice D reason: Hypoglycemia is not related to rheumatoid arthritis. RA primarily involves joint inflammation and systemic symptoms like fatigue and fever but does not directly impact blood sugar levels.

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The night nurse in the cardiac ICU has just received a report on several patients. Which of the following clients should the nurse prioritize for rounds?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client post-hypophysectomy. Which assessment finding is most important to report to the health care provider?

Correct Answer is C

Explanation

Correct Answer is C

Explanation

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