The nurse is receiving report on their patient assignments for the day. Which patient should be assessed first? The patient...

who reports a change in pattern of their usual shortness of breath

reports flank pain 7 on a (0-10) scale 15 min after getting an oral analgesic

with serosanguinous drainage in a JP drain post op day 3.

bilateral wheezes after walking 40 feet (12 meters), pulse ox 96 on RA

Answer and Explanation

The Correct Answer is A

A. A change in the pattern of shortness of breath can be a sign of worsening respiratory or cardiovascular status and may indicate a serious condition such as pulmonary embolism, heart failure, or a pneumothorax. This requires immediate assessment and further investigation to determine the cause.

B. While flank pain (7/10) after receiving oral analgesic could be concerning, the fact that the pain is still significant 15 minutes after medication administration suggests that the pain may not yet be well-controlled. However, this is not as immediately urgent as a change in breathing pattern, so this patient should be assessed after the one with respiratory concerns.

C. Serosanguinous drainage from a JP drain on postoperative day 3 is not uncommon, and this typically does not require immediate intervention unless the drainage increases significantly or becomes more sanguine. This patient should be assessed after the one with a change in shortness of breath.

D. Bilateral wheezes after walking 40 feet, with a pulse oximetry of 96% on room air, is concerning but not as urgent as a change in shortness of breath. The pulse oximetry is within the normal range, and wheezing could be related to mild exertion or an underlying chronic condition (like asthma), but the patient’s condition doesn’t seem to be immediately life-threatening. This patient should be assessed after the patient with shortness of breath.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. The pH is normal but leaning toward alkalosis (7.44).

The PaCO₂ is low (30 mmHg), indicating respiratory alkalosis.

The HCO₃⁻ is also low (18 mEq/L), showing metabolic compensation.

Since pH is within normal limits and both respiratory and metabolic components are abnormal, full compensation has occurred.

B. This is incorrect

C. This is incorrect

D. This is incorrect

A. variant B. Chronic stable C. Nocturnal D. Unstable

Correct Answer is D

Explanation

A. Variant angina: Also known as Prinzmetal's angina, this type of angina is caused by a spasm in the coronary arteries, which can temporarily restrict blood flow to the heart. While it can be severe, it is typically not associated with an impending myocardial infarction (MI). It often occurs at rest and is usually relieved with medications like nitrates or calcium channel blockers.

B. Chronic stable angina: This is the most common type of angina and occurs with physical exertion or emotional stress, typically following a predictable pattern. The pain is generally relieved with rest or nitroglycerin and is not usually associated with an impending myocardial infarction. Chronic stable angina is more of a symptom of underlying coronary artery disease (CAD) rather than an emergency situation.

C. Nocturnal angina: This occurs during sleep or while at rest, and it may be associated with coronary artery disease, but it is generally not an indicator of an impending MI. It can sometimes be relieved by sleeping in an upright position or using medications such as nitrates.

D. Unstable angina: This type of angina is the most concerning because it occurs unexpectedly and can happen at rest, with minimal physical activity, or at night. The pain is more severe, lasts longer, and may not be relieved by rest or nitroglycerin. Unstable angina is considered a medical emergency and is closely related to an impending myocardial infarction (MI). It signifies that a plaque in the coronary artery is unstable and may rupture, leading to a clot formation, which can completely block the artery and result in a heart attack.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is receiving report on their patient assignments for the day. Which patient should be assessed first? The patient...

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is analyzing a client's arterial blood gas (ABG) values with the following results: pH 7.44, PaCO2 30 mmHg. PaO2 90 mmHg, and HCO3 18 mEq/L. Which acid base imbalance should the nurse associate with these results? ABG pH 7.35-7.45 PC02 35-45 mmHg pa02 80-100 mmHg PHCO3 22-26 mEq/L

Correct Answer is A

Explanation

The nurse knows which of the following types of angina is most closely related with an impending myocardial infarction (MI)?

Correct Answer is D

Explanation

A client with a medical diagnosis of acute respiratory distress syndrome (ARDS) is being placed in the prone position. The nurse explains to family members that. "This will help improve ventilation by:

A nurse is caring for a client who has chronic renal disease and is receiving therapy with epoetin alfa. Which of the following laboratory results indicates a therapeutic effect of the medication to the nurse? An increase in....

A patient is in the progressive care unit on a ventilator. Which intervention(s) should the nurse implement? (SELECT ALL THAT APPLY)

What key feature should the nurse be aware of when ventilating clients with acute respiratory distress syndrome (ARDS)?

The nurse is caring for a patient diagnosed with Myasthenia Gravis (MG) prescribed plasmapheresis for treatment. Which statement by the nurse includes accurate education? "Plasmapheresis....

During acute respiratory distress syndrome (ARDS), the client's lung cells that produce surfactant have become damaged. The nurse knows this pathologic change will lead to what outcome?

Which of the following is the most important consideration in end-of-life care for a patient diagnosed with Huntington's Disease?

The nurse is developing a plan of care for a client admitted with hypoxemia related to altered alveolar diffusion. When formulating a plan of care the nurse is aware which intervention must be included?