Upon receiving a change-of-shift report about four patients in a heart failure unit, which patient should the nurse prioritize for assessment?
A patient who experienced dizziness after the first dose of captopril.
A patient exhibiting new-onset confusion, restlessness, and cool, clammy skin.
A patient on oxygen therapy with bilateral crackles at the lung bases.
A patient on IV nesiritide (Natrecor) with a blood pressure reading of 100/62.
The Correct Answer is B
Choice A rationale
While dizziness after the first dose of captopril can be concerning, it is not uncommon as the body adjusts to the medication. It is important to monitor this patient, but they are not the highest priority.
Choice B rationale
A patient exhibiting new-onset confusion, restlessness, and cool, clammy skin should be prioritized for assessment. These symptoms could indicate a serious condition such as shock or decreased cardiac output. This patient may be experiencing a rapid decline in condition and should be assessed immediately.
Choice C rationale
While a patient on oxygen therapy with bilateral crackles at the lung bases may have worsening heart failure, they are not the highest priority if they are stable. Crackles at the lung bases are a common finding in heart failure and indicate fluid accumulation in the lungs.
Choice D rationale
A patient on IV nesiritide (Natrecor) with a blood pressure reading of 100/62 is not the highest priority. While this blood pressure is on the lower side, it is not critically low.
Nesiritide can cause hypotension, so this patient should be monitored, but they are not the highest priority if they are stable.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Iron supplements for anemia do not typically interact with warfarin (Coumadin). Iron is a mineral that is essential for the production of red blood cells, and supplements are often prescribed to patients with anemia to increase their iron levels. While it’s important for healthcare providers to be aware of all medications and supplements a patient is taking, iron supplements are not known to diminish the effects of warfarin.
Choice B rationale
Furosemide (Lasix) is a diuretic medication used to treat fluid retention. It works by causing the kidneys to get rid of unneeded water and salt from the body into the urine. While furosemide can interact with other medications, it is not known to diminish the effects of warfarin.
Choice C rationale
Simvastatin (Zocor) is a medication used to control cholesterol levels. It works by slowing the production of cholesterol in the body to decrease the amount of cholesterol that may build up on the walls of the arteries and block blood flow to the heart, brain, and other parts of the body. Simvastatin does not typically interact with warfarin to diminish its effects.
Choice D rationale
Yaz (drospirenone/estradiol) is an oral contraceptive that contains estrogen. Estrogen can potentially increase the effects of warfarin, leading to an increased risk of bleeding. Therefore, if a patient taking warfarin also takes Yaz, it could potentially diminish the effects of warfarin, making it less effective. This is why it’s important for healthcare providers to be aware of all medications a patient is taking, including oral contraceptives.
Correct Answer is C
Explanation
Choice A rationale
A Ventricular septal defect (VSD) is a hole in the wall separating the two lower chambers of the heart. While it can cause cyanosis, it would not typically cause cyanosis only during crying or after feeding.
Choice B rationale
An Atrioventricular canal (AVC) defect is a combination of heart problems resulting in a defect in the center of the heart. While it can cause cyanosis, it would not typically cause cyanosis only during crying or after feeding.
Choice C rationale
Tetralogy of Fallot is a rare condition caused by a combination of four heart defects that are present at birth. These defects, which affect the structure of the heart, cause oxygen-poor blood to flow out of the heart and into the rest of the body. Infants and children with Tetralogy of Fallot usually have blue-tinged skin because their blood doesn’t carry enough oxygen. This is often more noticeable during episodes of crying or feeding.
Choice D rationale
An Atrial septal defect (ASD) is a hole in the wall between the two upper chambers of your heart (atria). The condition is present at birth (congenital). Small defects might be found by chance and never cause a problem. Some small atrial septal defects close during infancy or early childhood. While it can cause cyanosis, it would not typically cause cyanosis only during crying or after feeding.
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