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
Ulceration on the medial surface of the lower legs is not the best description of stasis dermatitis in a patient with peripheral vascular disease (PVD). While ulcers can occur in severe cases, they are not the primary characteristic of stasis dermatitis.
Choice B rationale
Stasis dermatitis, also known as venous stasis dermatitis, is a skin inflammation that occurs in people with poor circulation. It most often happens in the lower legs because that’s where blood typically collects. When blood pools in the veins of the lower leg, it can cause a variety of symptoms, including a brownish skin discoloration on the lower legs. This discoloration is caused by the leakage of red blood cells into the skin due to increased pressure in the veins.
Choice C rationale
While edema in the lower legs can be a symptom of PVD and may accompany stasis dermatitis, it is not the best description of the condition. Edema is a general symptom that can occur in many conditions and is not specific to stasis dermatitis.
Choice D rationale
A purple rash on the medial surface of the lower legs is not a typical symptom of stasis dermatitis. While the skin may become discolored, it is usually a brownish color rather than purple.
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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