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 B
Explanation
Choice A rationale
A pleural friction rub is an audible raspy breathing sound, a medical sign present in some patients with pleurisy and other conditions affecting the chest cavity. It is not a typical symptom of cardiac tamponade.
Choice B rationale
Distended neck veins are a result of the collapsed blood vessels that should return blood to the heart. This is a common symptom of cardiac tamponade.
Choice C rationale
Widening pulse pressure occurs with valvular heart disease, not typically with cardiac tamponade.
Choice D rationale
Bradycardia, or a slower-than-normal heart rate, is not typically associated with cardiac tamponade.
Correct Answer is C
Explanation
Choice A rationale
While obesity can contribute to hypertension and other cardiovascular diseases, it is not a contraindication for the use of propranolol. Weight management would be part of the overall treatment plan for hypertension, but it would not prevent the use of this medication.
Choice B rationale
Age is not a contraindication for the use of propranolol. While older adults may be more susceptible to certain side effects of the medication, age alone would not prevent a patient from taking propranolol.
Choice C rationale
Diabetes is a contraindication for the use of propranolol. Propranolol is a non-selective beta- blocker, which can mask symptoms of hypoglycemia, a common condition in people with diabetes. Therefore, it’s generally not recommended for people with diabetes.
Choice D rationale
Race is not a contraindication for the use of propranolol. While there are some differences in how people of different races may respond to certain medications, race alone would not prevent a patient from taking propranolol.
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