The nurse is caring for clients on a cardiac unit. Which client would the nurse assess first?
The client diagnosed with endocarditis who has a temperature of 100°F.
The client diagnosed with cardiomyopathy who has bilateral 4+ peripheral edema.
The client diagnosed with aortic valve stenosis who has weakness.
The client diagnosed with angina who is reporting chest pain.
The Correct Answer is D
A. The client diagnosed with endocarditis who has a temperature of 100°F: A low-grade fever in endocarditis should be monitored, but it is not immediately life-threatening. While infection is a concern, it does not require urgent intervention compared with acute cardiac symptoms.
B. The client diagnosed with cardiomyopathy who has bilateral 4+ peripheral edema: Severe edema indicates fluid overload and chronic heart failure, but it is generally a slower-developing complication. Assessment and interventions are important, but it is not as urgent as new-onset chest pain.
C. The client diagnosed with aortic valve stenosis who has weakness: Weakness may indicate decreased cardiac output, but unless accompanied by other acute signs like hypotension, chest pain, or syncope, it is lower priority compared with ongoing chest pain.
D. The client diagnosed with angina who is reporting chest pain: Acute chest pain can indicate myocardial ischemia or an evolving myocardial infarction, which is life-threatening. Immediate assessment and intervention to relieve pain, monitor vital signs, and prevent cardiac complications take priority over other stable or chronic conditions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["29.7"]
Explanation
Convert the client’s weight to kilograms
Weight in kg = 181.4 ÷ 2.2
= 82.45 kg
Calculate the heparin dose in units per hour
Dose (units/hr) = 18 units/kg/hr × 82.45 kg
= 1484.1 units/hr
Identify the concentration of heparin from the label
Concentration = 25,000 units / 500 mL
= 50 units/mL
Calculate the flow rate in mL/hr
Flow Rate = Dose ÷ Concentration
Flow Rate = 1484.1 ÷ 50
≈ 29.682 mL/hr
Round to the nearest tenth
= 29.7 mL/hr
Correct Answer is A
Explanation
A. Prepare for transcutaneous pacing: The client is symptomatic with sinus bradycardia, hypotension, syncope, and weakness, indicating hemodynamic instability. Transcutaneous pacing provides temporary electrical stimulation to increase heart rate and maintain adequate perfusion until definitive treatment can be initiated.
B. Administer an antiarrhythmic medication: Antiarrhythmic drugs are used to treat tachyarrhythmias, not symptomatic bradycardia. Administering such medications could worsen the bradycardia and further compromise cardiac output.
C. Prepare for synchronized cardioversion: Synchronized cardioversion is indicated for unstable tachyarrhythmias, such as atrial fibrillation or ventricular tachycardia with a pulse. It is not appropriate for bradycardia and could be harmful.
D. Administer a thrombolytic medication: Thrombolytic therapy is used for acute myocardial infarction or thromboembolic events, not for bradycardia. There is no evidence of an occlusive clot causing the current hemodynamic instability.
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