Which client should the telemetry nurse assess first after receiving the a.m. shift report?
The client diagnosed with mitral valve stenosis who has heart palpitations.
The client diagnosed with arterial occlusive disease who has intermittent claudication.
The client diagnosed with deep vein thrombosis who has an edematous right calf.
The client diagnosed with heart failure who has pink frothy sputum.
The Correct Answer is D
Choice A reason: The client with mitral valve stenosis experiencing heart palpitations is at risk of complications such as atrial fibrillation, which can lead to embolic events. While this is a serious condition that needs attention, it is not as immediately life-threatening as the presence of pink frothy sputum in a heart failure patient.
Choice B reason: The client with arterial occlusive disease and intermittent claudication is experiencing pain due to reduced blood flow to the extremities during activity. Although this condition requires management to prevent worsening ischemia, it is not as critical as the presentation of pink frothy sputum in a heart failure patient.
Choice C reason: The client with deep vein thrombosis (DVT) and an edematous right calf is at risk of developing a pulmonary embolism, which is a serious condition. However, the immediate symptoms do not suggest a current life-threatening emergency compared to the client with heart failure and pink frothy sputum.
Choice D reason: The client with heart failure who has pink frothy sputum must be assessed first. Pink frothy sputum is a sign of pulmonary edema, indicating severe left-sided heart failure. This condition is a medical emergency as it impairs gas exchange and can lead to respiratory failure if not promptly treated. Immediate intervention is necessary to stabilize the client's respiratory and cardiac status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Obtaining daily weights of the client is the best action to assess the therapeutic effect of furosemide in managing early chronic kidney disease. Daily weights provide valuable information about fluid balance and the effectiveness of the diuretic in reducing fluid retention. Consistent weight monitoring helps determine if the medication is achieving its goal of managing fluid overload, which is a common issue in CKD patients.
Choice B reason: Assessing acid-base balance is important in managing CKD, but it is not the primary action to assess the therapeutic effect of furosemide. While diuretics can influence electrolyte levels and acid-base balance, monitoring fluid status through daily weights is more directly related to evaluating the effectiveness of the medication.
Choice C reason: Assessing the client's serum creatinine is crucial for monitoring kidney function and progression of CKD. However, it is not the primary action to determine the therapeutic effect of furosemide. The focus of furosemide therapy is to manage fluid balance, and daily weights provide a more immediate and relevant assessment of this effect.
Choice D reason: Auscultating heart sounds is part of a comprehensive assessment of a CKD patient, but it is not the best action to evaluate the therapeutic effect of furosemide. Heart sounds can provide information about cardiac function and potential complications, but they do not directly measure the effectiveness of fluid management achieved by the diuretic.
Correct Answer is D
Explanation
Choice A reason: Neurogenic shock is a type of distributive shock that occurs due to a sudden loss of sympathetic nervous system signals to the smooth muscle in vessel walls. It is not a direct complication of septic shock, which is primarily caused by severe infection and systemic inflammation. While both are forms of shock, the mechanisms and causes are different.
Choice B reason: Febrile seizures are typically seen in children with high fevers and are not a common complication of septic shock in adults. Septic shock involves severe infection and systemic inflammatory response, leading to complications such as organ failure rather than febrile seizures.
Choice C reason: Esophageal varices are enlarged veins in the esophagus that can bleed, often seen in patients with liver disease and portal hypertension. They are not a complication of septic shock. While severe infection and systemic inflammation can lead to various complications, esophageal varices are specifically related to liver pathology.
Choice D reason: Acute Respiratory Distress Syndrome (ARDS) is a severe complication that the nurse should remain alert for in patients with septic shock. ARDS is characterized by rapid onset of widespread inflammation in the lungs, leading to respiratory failure. It is a common and serious complication of septic shock due to the systemic inflammatory response affecting the lung tissue. Early recognition and management are crucial for improving patient outcomes.
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