The nurse is caring for a group of patients. Which of the the following patients should the nurse evaluate first?
A patient with coronary artery disease (CAD) who reports chest pain radiating to the jaw.
A patient with venous insufficiency with 2+ pitting edema.
A patient receiving enoxaparin (Lovenox) for experiencing an MI 3 days ago.
A patient with peripheral artery disease (PAD) with a diminished pulse.
The Correct Answer is A
A. A patient with coronary artery disease (CAD) who reports chest pain radiating to the jaw: This patient should be evaluated first. Chest pain radiating to the jaw can be a sign of a heart attack, which is a life-threatening condition. Immediate medical attention is required to prevent further damage to the heart muscle.
B. A patient with venous insufficiency with 2+ pitting edema: While this patient’s condition needs to be addressed, it is not as immediately life-threatening as a potential heart attack. Venous insufficiency and edema can lead to discomfort and complications if left untreated, but these complications are typically not immediate.
C. A patient receiving enoxaparin (Lovenox) for experiencing an MI 3 days ago: This patient is already receiving treatment for their condition. While they should be monitored for side effects of the medication and signs of further cardiac issues, they are not the highest priority based on the information given.
D. A patient with peripheral artery disease (PAD) with a diminished pulse: While a diminished pulse can indicate poor blood flow, which can lead to complications such as tissue damage and non-healing wounds, it is not as immediately life-threatening as a potential heart attack. This patient should be evaluated, but they are not the highest priority based on the information given.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Increase in postoperative pain: Preoperative teaching typically includes information about pain management strategies, which should help to reduce, not increase, postoperative pain.
B. Reduced postoperative anxiety: This is correct. One of the key benefits of preoperative education is reduced anxiety. By understanding what to expect before, during, and after surgery, patients are often less anxious about the procedure.
C. Reduced postoperative respiratory function: Preoperative teaching usually includes instructions on deep breathing and coughing exercises to help prevent respiratory complications after surgery. Therefore, it should improve, not reduce, postoperative respiratory function.
D. Increased length of postoperative care in the health care facility: Preoperative education has been shown to reduce the length of hospital stay. By better understanding their surgery and postoperative care, patients are often able to recover more quickly and leave the hospital sooner
Correct Answer is ["A","B","E"]
Explanation
A. "Report any incidents of swelling to your lips, tongue or face."
Angioedema is a serious side effect of lisinopril, which is an ACE inhibitor. Swelling of the lips, tongue, or face can indicate angioedema, which can be life-threatening and requires immediate medical attention.
B. "Report the development of a persistent dry cough."
A persistent dry cough is a common side effect of ACE inhibitors like lisinopril. If this occurs, the healthcare provider should be notified as an alternative medication may be needed.
C. "Your cholesterol levels should be monitored monthly while taking this medication."
Monitoring cholesterol levels is not typically necessary for clients taking lisinopril. This instruction is more relevant for medications affecting lipid levels, such as statins.
D. "Make sure your diet contains a lot of potassium-rich foods."
Lisinopril can cause hyperkalemia (high potassium levels). Therefore, it is important to avoid excessive intake of potassium-rich foods to prevent complications. Clients should be advised to monitor potassium intake rather than increase it.
E. "Monitor your blood pressure on a regular basis."
Regular monitoring of blood pressure is essential for clients taking lisinopril to ensure the medication is effectively managing their hypertension and to adjust dosages as necessary.
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