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 D

Explanation

A. Insert the IV catheter:

Inserting an IV catheter is necessary to administer IV fluids and medications. However, it is not the most immediate need. The priority is to address the client's oxygenation status first to stabilize them before proceeding with other interventions.

B. Obtain a blood sample:

Obtaining a blood sample for cardiac enzyme levels is important to diagnose a myocardial infarction. Nevertheless, this step should be taken after ensuring the client is receiving adequate oxygen, as hypoxia needs to be addressed immediately.

C. Attach the leads for a 12-lead ECG:

Attaching the leads for a 12-lead ECG is crucial for diagnosing the client's cardiac condition. However, it should be done after initiating oxygen therapy, as improving the client's oxygenation status is more urgent and can help stabilize the client for further diagnostic procedures.

D. Initiate oxygen therapy:

Initiating oxygen therapy is the most critical first action. The client is experiencing severe chest pain, shortness of breath, and signs of cyanosis, indicating that their oxygen levels are insufficient. Providing oxygen at 4 L/min via nasal cannula will help alleviate hypoxia, improve the client's condition, and provide time for further diagnostic and therapeutic interventions.

A. Treatment B. List of medications C. Medical condition D. Vital signs

Correct Answer is C

Explanation

(A) Treatment: While treatment is an important part of the client’s information, it is typically included in the “Recommendation” component of ISBARR, where the nurse would discuss the recommended treatment plan.

(B) List of medications: The list of medications a client is taking is crucial information, but it is usually included in the “Background” component of ISBARR, which provides context about the client’s medical history and current medications.

(C) Medical condition: This is the most appropriate answer. The “Situation” component of ISBARR is meant to provide a brief overview of the client’s current situation, which includes their current medical condition or reason for admission.

(D) Vital signs: Vital signs are typically included in the “Assessment” component of ISBARR, where the nurse would discuss the results of their assessment of the client, including vital signs.

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

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

Correct Answer is C

Explanation

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