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The nurse is caring for a team of assigned clients. Which client is a priority for the nurse to check on first?

The client with a history of a myocardial infarction who has a p wave before every QRS complex.

The client diagnosed with heart failure who has bilateral 2+ pitting pedal edema.

The client with sinus bradycardia (HR 56/min) that is reporting fatigue.

The client diagnosed with coronary artery disease who is now reporting new onset of severe indigestion.

Answer and Explanation

The Correct Answer is D

A. The client with a history of a myocardial infarction who has a p wave before every QRS complex.

This may indicate a heart block, which requires attention. However, it's not an immediate life-threatening situation.

B. The client diagnosed with heart failure who has bilateral 2+ pitting pedal edema.

Bilateral pitting pedal edema is a sign of fluid overload, which is concerning and requires attention.

C. The client with sinus bradycardia (HR 56/min) that is reporting fatigue.

While bradycardia and fatigue are concerns, they might not be as urgent as the client with fluid overload.

D. The client diagnosed with coronary artery disease who is now reporting new onset of severe indigestion.

New onset of severe indigestion in a client with coronary artery disease raises concern for a potential cardiac event, and this should be addressed promptly.

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Correct Answer is D

Explanation

A. Intake and output:

Intake and output refer to monitoring the amount of fluids a person consumes (intake) and eliminates (output) through urine, feces, and other means. While tracking fluid intake and output is important, it may not provide a direct indication of excess fluid retention.

B. Pitting pedal edema:

Pitting pedal edema is swelling in the lower extremities, particularly the ankles and feet, that leaves an indentation (pit) when pressure is applied. This can be a sign of fluid retention but may not always be the earliest or most reliable indicator.

C. Crackles in the bases of the lungs:

Crackles or rales in the bases of the lungs can be indicative of pulmonary congestion, which may occur due to fluid accumulation. However, crackles alone may not always be specific to fluid overload and can be present in other respiratory conditions.

D. Daily weights:

Daily weights are a critical and sensitive measure for assessing fluid balance. Sudden weight gain, especially over a short period, can be a strong indicator of fluid retention. Monitoring weight on a daily basis helps to detect changes early, allowing for prompt intervention.

A. Visible clubbing of the fingers and toes B. Unequal peripheral pulses between extremities C. Reddened extremities with muscle atrophy D. Loss of hair on the distal extremities

Correct Answer is D

Explanation

A. Visible clubbing of the fingers and toes

Clubbing is a condition characterized by changes in the shape and appearance of the fingers and toes. It involves enlargement of the fingertips and the nails becoming curved and rounded. Clubbing is not typically associated with peripheral arterial occlusive disease (PAD). It is more commonly seen in conditions such as chronic respiratory or cardiovascular diseases.

B. Unequal peripheral pulses between extremities

Unequal peripheral pulses can be indicative of vascular abnormalities. However, in PAD, the characteristic finding is diminished or absent pulses rather than unequal pulses between extremities. Other conditions, such as arterial embolism or thrombosis, may present with unequal pulses.

C. Reddened extremities with muscle atrophy

Reddened extremities and muscle atrophy are not typical findings in PAD. These symptoms are more characteristic of conditions associated with chronic inflammation or compromised venous circulation, such as chronic venous insufficiency or venous stasis.

D. Loss of hair on the distal extremities

Loss of hair on the distal extremities, particularly on the lower legs and feet, is a common finding in PAD. It results from reduced blood flow and oxygen supply to the hair follicles in the affected areas.

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The nurse is caring for a team of assigned clients. Which client is a priority for the nurse to check on first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What is the best indication if the client with congestive heart failure is holding excess fluid?

Correct Answer is D

Explanation

The nurse is providing care for a client recently diagnosed with peripheral arterial occlusive disease (PAD). What assessment finding is most consistent with this diagnosis?

Correct Answer is D

Explanation

An emergency department nurse is assessing an adult woman for a suspected myocardial infarction (MI). When planning the assessment, the nurse should be aware that female patients may have which of the following symptoms for an MI? (SELECT ALL THAT APPLY)

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A client is ordered to receive 4 g of a medication. The pharmacy has the medication available in a concentration of 160 mg per 5 mL. How many mL should the client receive?

A critical-care nurse is caring for a client diagnosed with pneumonia as a surgical complication. The nurse’s assessment reveals that the client has an increased work of breathing due to copious tracheobronchial secretions. What should the nurse encourage the patient to do?

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A community health nurse teaches a group of seniors at an assisted living facility about modifiable risk factors that contribute to the development of peripheral arterial disease (PAD). The nurse knows that the teaching was effective based on which of the following statements?