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 C

Explanation

A. Verify that the client's valuables have been secured:

While securing the client's valuables is important for their safety and security during hospitalization, it does not directly address the prevention of postoperative complications.
B. Discuss a discharge date with the client:

Discussing a discharge date is part of discharge planning but does not directly address the prevention of postoperative complications.
C. Inform the client about the need for sequential compression devices:

Sequential compression devices (SCDs) are mechanical devices that help prevent venous stasis and deep vein thrombosis (DVT) by promoting circulation in the lower extremities. They are commonly used in surgical patients to reduce the risk of blood clots and related complications.
D. Review the facility's visitation policy with the client and family:

Reviewing the facility's visitation policy is important for ensuring that the client and family understand the rules and regulations regarding visitors. While visitor policies contribute to the overall well-being of the client during their hospital stay, they do not directly address the prevention of postoperative complications like the use of sequential compression devices does.

A. Heart rate of 66/min B. BP of 148/94 mm Hg C. Peripheral edema of the ankles D. A digoxin level of 1.2 ng/mL.

Correct Answer is C

Explanation

(a) Heart rate of 66/min:
A heart rate of 66/min is within the normal range (60-100 bpm) and does not typically require contacting the provider before administering a calcium channel blocker. CCBs can affect heart rate, but this finding alone is not a contraindication for their use.

(b) BP of 148/94 mm Hg:
A blood pressure reading of 148/94 mm Hg indicates hypertension, which is an appropriate indication for the use of calcium channel blockers. This finding supports the use of the medication rather than requiring the provider to be contacted.

(c) Peripheral edema of the ankles:
Peripheral edema is a known side effect of calcium channel blockers. If the client is already experiencing edema, administering the medication could potentially worsen this condition. The nurse should contact the provider to discuss this finding before proceeding with the medication administration.

(d) A digoxin level of 1.2 ng/mL:
A digoxin level of 1.2 ng/mL is within the therapeutic range (0.5-2.0 ng/mL). This finding does not necessitate contacting the provider before administering a calcium channel blocker, as it does not indicate toxicity or a contraindication for CCB use

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