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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.75"]
Explanation
The nurse needs to calculate the correct dose of atropine for a client who has a prescription for 0.3 mg IV stat. The nurse knows that atropine is a medication that blocks the effects of the parasympathetic nervous system and is used to treat bradycardia, heart block, and some types of poisoning.
To find out how many milliliters of atropine the nurse will administer, the nurse can use the formula:
Dose ordered / Dose available = Volume to administer
Plugging in the values, the nurse gets:
0.3 mg / 0.4 mg per mL = 0.75 mL
Therefore, the nurse will administer 0.75 mL of atropine to the client IV stat.
Correct Answer is B
Explanation
A. Standard precautions:
Standard precautions are the basic level of infection control and should be used for all patient care. These precautions include practices like hand hygiene, the use of personal protective equipment (PPE), and safe injection practices.
B. Airborne precautions:
These precautions are used to prevent the transmission of infectious agents that are spread through the air. In the case of tuberculosis (TB), which is caused by Mycobacterium tuberculosis, airborne precautions are necessary to reduce the risk of airborne transmission.
C. Contact precautions:
Contact precautions are used for patients with known or suspected infections that can be transmitted by direct or indirect contact. Examples include Clostridium difficile infection and multidrug-resistant organisms. These precautions involve the use of PPE and may include patient placement in a private room.
D. Droplet precautions:
Droplet precautions are used when a patient is known or suspected to be infected with pathogens that are transmitted by respiratory droplets. Examples include influenza and certain types of bacterial meningitis. These precautions include placing the patient in a private room and using PPE.
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