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 B

Explanation

Choice A reason: Lying on the side with the head of the bed at 30 degrees may provide some comfort but is not the most effective position for easing breathing in COPD patients. Sitting upright allows for better lung expansion.

Choice B reason: Sitting on the edge of the bed with the arms supported is known as the tripod position. This position helps patients with COPD breathe more easily by allowing the diaphragm to move more freely and reducing the work of breathing.

Choice C reason: Laying in a supine position with arms crossed is not beneficial for COPD patients. This position can restrict lung expansion and make breathing more difficult.

Choice D reason: Sleeping in a prone position with legs elevated is not recommended for COPD patients. It can further restrict breathing and is uncomfortable for patients with respiratory issues.

A. "I can change who serves as my health care proxy at any time." B. "The health care proxy does not go into effect until I am incapable of making decisions." C. "I have to choose a family member as my health proxy." D. "My health care proxy can make decisions on my behalf if I am unable to do so."

Correct Answer is C

Explanation

Choice A reason: The statement "I can change who serves as my health care proxy at any time" is correct. A client can modify or revoke their health care proxy designation as long as they are mentally competent.

Choice B reason: The statement "The health care proxy does not go into effect until I am incapable of making decisions" is accurate. The health care proxy is activated when the client is unable to make their own medical decisions.

Choice C reason: The statement "I have to choose a family member as my health proxy" indicates a need for clarification. A client is not required to choose a family member as their health care proxy; they can select any trusted individual to act in this capacity.

Choice D reason: The statement "My health care proxy can make decisions on my behalf if I am unable to do so" is correct. The purpose of a health care proxy is to appoint someone to make medical decisions when the client is incapacitated.

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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

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