The nurse has received a change-of-shift report on the following clients. Which client should the nurse see first?

A patient with second-degree atrioventricular (AV) block, type 1. rate 60, who is dizzy when ambulating

A patient who is in a sinus rhythm, rate 98 and regular, recovering from an elective cardioversion 2 hours ago

A patient with atrial fibrillation, rate 88 and irregular, who has a dose of warfarin (Coumadin) due

A patient whose implantable cardioverter-defibrillator (ICD) fired twice today and has a dose of amiodarone (Cordarone) due.

Answer and Explanation

The Correct Answer is D

A. A patient with second-degree atrioventricular (AV) block, type 1, rate 60, who is dizzy when ambulating. While dizziness may be a concern, second-degree AV block type 1 (Wenckebach) typically resolves without immediate intervention.

B. A patient who is in a sinus rhythm, rate 98 and regular, recovering from an elective cardioversion 2 hours ago. This patient is stable, and recovery from cardioversion typically involves monitoring, but the patient does not require immediate intervention.

C. A patient with atrial fibrillation, rate 88 and irregular, who has a dose of warfarin (Coumadin) due. The patient is stable, and the dose of warfarin can be administered after assessing the patient’s overall condition, making it a lower priority.

D. A patient whose implantable cardioverter-defibrillator (ICD) fired twice today and has a dose of amiodarone (Cordarone) due: The patient whose ICD fired twice is at high risk for life-threatening arrhythmias, and this situation requires immediate evaluation and intervention. The nurse should assess the patient first, and the dose of amiodarone may be administered to manage any underlying arrhythmias.

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Correct Answer is C

Explanation

A. Thrombotic stroke. A thrombotic stroke develops more gradually and is not typically associated with such sudden and severe symptoms.

B. Embolic stroke. An embolic stroke is often associated with a known embolic source, such as a clot from the heart, and can present more suddenly, but without all the symptoms seen here.

C. Hemorrhagic stroke: Hemorrhagic strokes often present with a sudden, severe headache, vomiting, seizure activity, and high blood pressure. A fever may also develop due to increased intracranial pressure.

D. Transient ischemic attack (TIA). TIAs are brief and resolve within minutes to hours and do not typically cause seizures.

A. Decreased peripheral pulses B. S3 heart murmur C. Distended neck veins D. Orthopnea

Correct Answer is C

Explanation

A. Decreased peripheral pulses. Decreased pulses may be related to poor perfusion but are not a hallmark sign of right-sided heart failure.

B. S3 heart murmur. An S3 heart murmur is associated with left-sided heart failure due to fluid overload in the lungs.

C. Distended neck veins: Right-sided heart failure leads to the backup of blood in the systemic circulation, which often causes jugular vein distention (JVD), peripheral edema, and hepatomegaly.

D. Orthopnea. Orthopnea is a symptom of left-sided heart failure, where fluid builds up in the lungs, making it difficult to breathe when lying flat.

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The nurse has received a change-of-shift report on the following clients. Which client should the nurse see first?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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