The nurse has just received a change-of-shift report for 4 clients on the coronary step-down unit. Which client will the nurse assess first?
A client who underwent coronary angioplasty yesterday who is requesting to sit in the bedside chair.
A client with dilated cardiomyopathy who developed dyspnea and agitation 1 hour prior to shift change.
A client who is two days postoperative coronary artery bypass grafting and has a temperature of 100.6F.
A client with mitral valve stenosis who is scheduled for a balloon valvuloplasty later today.
The Correct Answer is B
A. A client who underwent coronary angioplasty yesterday who is requesting to sit in the bedside chair: Sitting in a chair is a routine activity and does not indicate an immediate change in clinical status. While safety and mobility should be assessed, this client is stable and does not require immediate priority over acute symptoms.
B. A client with dilated cardiomyopathy who developed dyspnea and agitation 1 hour prior to shift change: Dyspnea and agitation are signs of possible acute decompensated heart failure, hypoxia, or pulmonary edema. These symptoms indicate a potentially life-threatening change in condition and require immediate assessment to ensure airway, breathing, and hemodynamic stability. This client has the highest priority.
C. A client who is two days postoperative coronary artery bypass grafting and has a temperature of 100.6°F: A mild postoperative fever is relatively common and may reflect normal inflammatory response. While it should be monitored, it is not immediately life-threatening and is lower priority compared with acute respiratory distress.
D. A client with mitral valve stenosis who is scheduled for a balloon valvuloplasty later today: Preoperative assessment and preparation are important, but unless the client is unstable, this is not as urgent as new-onset dyspnea and agitation. Preprocedure evaluation can be addressed after assessing acute changes in other clients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Muted systolic murmur: Mitral valve stenosis typically produces a diastolic murmur, not a systolic one. A muted systolic murmur does not specifically indicate progression of mitral stenosis.
B. Dyspnea on exertion: As mitral stenosis progresses, the narrowed valve obstructs blood flow from the left atrium to the left ventricle. This increases left atrial pressure and leads to pulmonary congestion. Dyspnea on exertion is a classic early sign of worsening mitral stenosis and indicates disease progression.
C. Upper extremity weakness: Weakness of the upper extremities is not a typical manifestation of mitral valve stenosis progression. It may suggest a neurologic or musculoskeletal issue instead.
D. Oxygen saturation of 93%: Although slightly decreased, an oxygen saturation of 93% is only mildly low and not specific for progression of mitral stenosis. Dyspnea related to pulmonary congestion is a more significant and classic indicator.
Correct Answer is A
Explanation
A. Prepare for transcutaneous pacing: The client is symptomatic with sinus bradycardia, hypotension, syncope, and weakness, indicating hemodynamic instability. Transcutaneous pacing provides temporary electrical stimulation to increase heart rate and maintain adequate perfusion until definitive treatment can be initiated.
B. Administer an antiarrhythmic medication: Antiarrhythmic drugs are used to treat tachyarrhythmias, not symptomatic bradycardia. Administering such medications could worsen the bradycardia and further compromise cardiac output.
C. Prepare for synchronized cardioversion: Synchronized cardioversion is indicated for unstable tachyarrhythmias, such as atrial fibrillation or ventricular tachycardia with a pulse. It is not appropriate for bradycardia and could be harmful.
D. Administer a thrombolytic medication: Thrombolytic therapy is used for acute myocardial infarction or thromboembolic events, not for bradycardia. There is no evidence of an occlusive clot causing the current hemodynamic instability.
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