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 C
Explanation
Choice A rationale
Reducing the overall contractility of the heart muscle is not the primary reason for performing Coronary Artery Bypass Surgery (CABG)4. In fact, reducing the contractility of the heart muscle could potentially decrease the heart’s ability to pump blood effectively.
Choice B rationale
Reducing plaque buildup in the carotid artery is not the primary reason for performing CABG4. While plaque buildup in the carotid artery can lead to serious conditions such as stroke, CABG is specifically performed to bypass blocked coronary arteries, not carotid arteries.
Choice C rationale
Increasing the oxygen supply to the heart muscle is the primary reason for performing CABG4. When coronary arteries become blocked or narrowed due to plaque buildup, the heart muscle may not receive enough oxygen-rich blood. CABG is performed to create a new route, or bypass, around the blocked artery, which improves blood flow and oxygen supply to the heart muscle.
Choice D rationale
Increasing the myocardial workload is not the primary reason for performing CABG4. In fact, increasing the workload of the heart could potentially exacerbate heart disease and lead to complications such as heart failure.
Correct Answer is ["B","C","D","E"]
Explanation
Choice A rationale
Advocating for a diet rich in saturated fats is not a recommended strategy to prevent cardiovascular disease. Saturated fats can raise the level of cholesterol in your blood and increase your risk of heart disease.
Choice B rationale
Recommending cessation of smoking is a crucial intervention to prevent cardiovascular disease. Chemicals in tobacco can damage the heart and blood vessels, leading to narrowing of the arteries (atherosclerosis), which can ultimately lead to a heart attack.
Choice C rationale
Regular blood pressure monitoring is important as high blood pressure is a significant risk factor for heart disease. Controlling blood pressure helps ensure that your heart is not working harder than it should be, which can prevent damage to your heart and arteries.
Choice D rationale
Regular cholesterol screenings are essential because high levels of cholesterol can lead to the buildup of plaques in your arteries, increasing your risk of heart disease.
Choice E rationale
Regular physical exercise helps control your weight and can reduce your chances of developing other conditions that may put a strain on your heart, such as high blood pressure, high cholesterol, and diabetes.
Choice F rationale
Suggesting no more than 5 alcoholic drinks a day is not a recommended strategy to prevent cardiovascular disease. In fact, it is advised to limit alcohol intake as excessive drinking can lead to high blood pressure, heart failure, or even stroke.
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