The nurse is assigned to the cardiac unit caring for four clients. He is preparing to do initial rounds. Which client should the nurse assess first?
A client with left-sided heart failure on oxygen via nasal cannula
A client with syncope who is being discharged today
A client scheduled for a cardiac ultrasound this morning
A client with controlled atrial fibrillation with a heart rate of 82
The Correct Answer is A
A. A client with left-sided heart failure on oxygen via nasal cannula: This client is at risk for respiratory distress due to pulmonary congestion. Immediate assessment is needed to ensure oxygenation and manage potential deterioration.
B. A client with syncope who is being discharged today: This client is stable if being discharged, so assessment can be delayed.
C. A client scheduled for a cardiac ultrasound this morning: This is a non-urgent diagnostic procedure and does not take priority.
D. A client with controlled atrial fibrillation with a heart rate of 82: Controlled atrial fibrillation indicates stability, so this client can be assessed later.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D","E","F","G"]
Explanation
A. Morphine is typically used for pain relief, but it is not used to reduce cerebral edema.
B. Lactated Ringers is a balanced electrolyte solution, but it does not address the need for reducing cerebral edema.
D. Dexamethasone is a corticosteroid used to reduce inflammation and cerebral edema in cases of brain injury.
E. Mannitol is an osmotic diuretic used to reduce cerebral edema by drawing fluid out of the brain and into the bloodstream.
F. Hypertonic saline is used to increase serum osmolality, helping to pull water out of the brain and reduce edema.
G. Furosemide is a loop diuretic that can also help reduce cerebral edema by promoting diuresis.
Correct Answer is A
Explanation
A. Administer oxygen via nasal cannula: The client's symptoms of dyspnea, chest pain, syncope, and hypotension suggest a possible acute cardiovascular event, such as a myocardial infarction (MI) or pulmonary embolism (PE). Administering oxygen should be the priority to improve oxygenation and prevent hypoxia, which could exacerbate the client's symptoms and further compromise cardiac function.
B. Administer prescribed pain medications. Pain relief may be necessary, but stabilizing oxygen levels is the priority.
C. Administer NS IV fluid. Fluid administration may be helpful, but oxygenation is more critical in this situation to address the potential underlying respiratory or cardiac issue.
D. Ask the provider for a dopamine prescription. While dopamine may be used in cases of shock, the immediate action should be to ensure the client is adequately oxygenated.
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