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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A reason: Nausea is a common symptom of digoxin toxicity. Elevated levels of digoxin can cause gastrointestinal disturbances, including nausea.
Choice B reason: Vomiting is also a common symptom of digoxin toxicity. The medication can irritate the stomach and lead to vomiting.
Choice D reason: Hyperglycemia is not typically associated with digoxin toxicity. This symptom is unrelated to the effects of elevated digoxin levels.
Choice E reason: Photophobia is not a common symptom of digoxin toxicity. Symptoms of digoxin toxicity are more likely to be gastrointestinal or cardiovascular in nature.
Correct Answer is A
Explanation
Choice A reason: Right upper quadrant pain is a common clinical manifestation of cholecystitis, which is inflammation of the gallbladder. The pain is often severe and can radiate to the back or shoulder. It is usually triggered by the intake of fatty foods and may be accompanied by other symptoms such as nausea and vomiting.
Choice B reason: Right lower leg pain is not associated with cholecystitis. This type of pain could indicate other conditions such as deep vein thrombosis or musculoskeletal issues.
Choice C reason: A positive Babinski sign indicates central nervous system dysfunction and is not related to cholecystitis. It involves dorsiflexion of the big toe and fanning of the other toes when the sole of the foot is stimulated.
Choice D reason: Yawning at mass is irrelevant to the diagnosis of cholecystitis. It could indicate tiredness or boredom but has no clinical significance related to gallbladder inflammation.
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