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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

B) "I will keep my house at a cool temperature": This statement indicates a need for further teaching because maintaining a warm environment is recommended for individuals with Raynaud's phenomenon to prevent vasoconstriction and reduce the risk of attacks. Cold temperatures can trigger symptoms in individuals with this condition. Therefore, advising the client to keep their house warm is appropriate and aligns with preventive measures for Raynaud's phenomenon.

A) "I will try to anticipate and avoid stressful situations": Stress management is an essential aspect of managing Raynaud's phenomenon, as stress can trigger vasospasms. Anticipating and avoiding stressful situations can help reduce the frequency and severity of symptoms.

C) "I will complete the smoking cessation program I started": Smoking cessation is crucial for individuals with Raynaud's phenomenon because smoking narrows blood vessels and exacerbates symptoms. Completing a smoking cessation program is a positive step toward reducing the risk of vasospasms.

D) "I will wear gloves when removing food from the freezer": Wearing gloves when handling cold objects, such as food from the freezer, is recommended for individuals with Raynaud's phenomenon to prevent triggering attacks due to exposure to cold temperatures. This statement demonstrates an understanding of preventive measures for managing the condition.

A. Mannitol B. Spironolactone C. Hydrochlorothiazide D. Furosemide

Correct Answer is B

Explanation

A) Mannitol:
Mannitol is an osmotic diuretic that works by increasing the osmotic pressure in the glomerular filtrate, leading to increased urine output. It is not associated with causing hyperkalemia.

B) Spironolactone:
This is the correct choice. Spironolactone is a potassium-sparing diuretic that can put clients at risk for hyperkalemia. It works by blocking the action of aldosterone in the distal tubules of the kidneys, leading to decreased sodium reabsorption and increased potassium retention.

C) Hydrochlorothiazide:
Hydrochlorothiazide is a thiazide diuretic that promotes the excretion of sodium and water and can lead to potassium depletion (hypokalemia) rather than hyperkalemia.

D) Furosemide:
Furosemide is a loop diuretic that inhibits sodium and chloride reabsorption in the ascending loop of Henle. It can lead to potassium depletion (hypokalemia) rather than hyperkalemia.

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The nurse is caring for a group of patients. Which of the the following patients should the nurse evaluate first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client about how to prevent the onset of manifestations of Raynaud's phenomenon. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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