The nurse on the telemetry unit has just received the A.M. shift report.
Which client should the nurse assess first?
The client diagnosed with CHF who has 1+ pitting edema.
The client diagnosed with myocardial infarction who has an audible S3 heart sound.
The client with chronic renal failure who has an elevated creatinine level.
The client diagnosed with pneumonia who has a pulse oximeter reading of 94
The Correct Answer is B
Choice A rationale
Pitting edema of 1+ is a common manifestation of congestive heart failure due to increased hydrostatic pressure within the venous system. While it indicates fluid volume overload, it is typically a chronic finding and does not represent an immediate threat to the airway, breathing, or circulation. The nurse should monitor this finding during the shift, but it lacks the urgency required for a first assessment compared to acute cardiac changes in other patients.
Choice B rationale
An audible S3 heart sound in an adult who has suffered a myocardial infarction is a significant clinical finding. This ventricular gallop occurs during early diastole and often indicates the onset of heart failure or ventricular dysfunction. It suggests that the left ventricle is failing to pump effectively, leading to increased pressure. Given the high risk of rapid deterioration and cardiogenic shock after an infarct, this patient is the priority for immediate assessment and intervention.
Choice C rationale
Chronic renal failure is characterized by a persistent decrease in glomerular filtration rate, which naturally results in an elevated serum creatinine level. The normal creatinine range is approximately 0.6 to 1.2 mg/dL. In a client with known chronic disease, a high level is an expected baseline finding rather than an acute change. Unless the level is extremely high or accompanied by symptoms of uremic toxicity, this patient does not require the first assessment.
Choice D rationale
A pulse oximetry reading of 94 percent in a patient with pneumonia is generally considered acceptable and within a stable range. Most clinical protocols target an oxygen saturation of 92 percent or higher for patients with lung infections. While the nurse should continue to monitor respiratory effort and breath sounds, this saturation level indicates adequate gas exchange. It does not take precedence over a potential acute cardiac failure indicated by a new heart sound.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
A persistent, dry, nonproductive cough is a common side effect of ACE inhibitors due to the accumulation of bradykinin in the respiratory tract. However, instructing a client to take a cough suppressant is inappropriate because the cough is a pharmacological side effect that will not respond well to suppressants. If the cough becomes intolerable for the client, the healthcare provider must be notified to potentially switch the medication to an angiotensin II receptor blocker instead of masking the symptom.
Choice B rationale
Most ACE inhibitors can be taken without regard to food, though some specific ones like captopril have better absorption on an empty stomach. Telling a client to take it with food is not a universal requirement for this class of medication and is not the most critical safety instruction. The priority for discharge teaching focuses on safety and hemodynamic stability, such as managing the vascular changes that occur when the renin-angiotensin-aldosterone system is inhibited by the new medication regimen.
Choice C rationale
ACE inhibitors promote vasodilation and reduce fluid volume by blocking the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor. This reduction in peripheral vascular resistance can lead to a significant drop in blood pressure when changing positions. The nurse must instruct the client to rise slowly from a sitting or lying position to prevent falls and injury. This education is vital for safety, as orthostatic hypotension is a frequent and potentially dangerous adverse effect during initial therapy.
Choice D rationale
ACE inhibitors block the secretion of aldosterone, which normally promotes the excretion of potassium in the kidneys. By inhibiting this process, these medications can lead to hyperkalemia, where potassium levels exceed the normal range of 3.5 to 5.0 mEq/L. Encouraging the consumption of high-potassium foods like bananas increases the risk of developing cardiac arrhythmias due to dangerously high serum potassium levels. Clients should actually be cautioned against using salt substitutes or excessive potassium intake while on this medication.
Correct Answer is C
Explanation
Choice A rationale
Ibuprofen is a nonsteroidal anti-inflammatory drug that is generally discouraged immediately following a myocardial infarction or coronary intervention. It can increase the risk of cardiovascular events, such as reinfarction or stroke, by interfering with the antiplatelet effects of aspirin. Additionally, it may cause sodium retention and increase blood pressure, which adds unnecessary strain on the healing cardiac muscle. Patients are instead educated to use acetaminophen for minor pain management to avoid these risks.
Choice B rationale
Warfarin is an anticoagulant that inhibits vitamin K-dependent clotting factors, typically used for atrial fibrillation or prosthetic heart valves. While it prevents systemic emboli, it is not the standard medication for maintaining stent patency after a percutaneous transluminal coronary intervention. The primary concern after stent placement is platelet aggregation on the foreign metal surface. Warfarin alone does not adequately inhibit the specific pathways of platelet activation required to prevent acute or subacute stent thrombosis.
Choice C rationale
Plavix, or clopidogrel, is a P2Y12 receptor antagonist that inhibits platelet aggregation. Following percutaneous transluminal coronary intervention, especially with stent placement, dual antiplatelet therapy is essential. It prevents the formation of thrombi on the stent surface while the vessel wall undergoes endothelialization. Patients must be educated on the importance of strict adherence to this regimen to prevent catastrophic stent thrombosis. Common side effects include an increased risk of bruising and minor bleeding episodes.
Choice D rationale
Heparin is an intravenous or subcutaneous anticoagulant used in the acute hospital setting to provide immediate anticoagulation by potentiating antithrombin III. It is frequently used during the actual percutaneous procedure to prevent clotting on catheters and wires. However, it is not a discharge medication because it requires frequent monitoring of the partial thromboplastin time and is not available in a practical oral form. Long-term outpatient management relies on oral antiplatelet agents rather than heparin therapy.
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