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: Monitoring amylase and lipase levels is the best way to determine the effectiveness of treatment in a patient with pancreatitis. These enzymes are produced by the pancreas, and their levels in the blood increase significantly during an episode of pancreatitis. As treatment progresses and the inflammation of the pancreas decreases, the levels of these enzymes should return to normal. Therefore, checking the levels of amylase and lipase is a direct indicator of the patient's response to treatment.
Choice B reason: Hematocrit and hemoglobin levels are important for assessing overall blood volume and oxygen-carrying capacity, but they are not specific indicators of pancreatitis treatment effectiveness. While these levels can provide information about the patient's general health and hydration status, they do not specifically reflect changes in pancreatic inflammation.
Choice C reason: Red blood cell count is another measure of the blood's oxygen-carrying capacity and overall health, but like hematocrit and hemoglobin, it is not specific to pancreatitis. Changes in red blood cell count can occur due to various factors, but they do not provide direct information about the effectiveness of pancreatitis treatment.
Choice D reason: Serum uric acid levels are typically monitored in conditions such as gout or kidney stones, and they are not related to pancreatitis. Monitoring serum uric acid would not provide useful information about the patient's response to pancreatitis treatment.
Correct Answer is A
Explanation
Choice A reason: Administering normal saline 500-1000 mL infused over 1 hour is an effective fluid challenge to promote kidney perfusion in patients with acute kidney injury and no signs of fluid overload. This intervention helps increase intravascular volume, improving renal blood flow and potentially enhancing urine output.
Choice B reason: Administering drugs to suppress aldosterone release is not appropriate for promoting kidney perfusion in this context. Suppressing aldosterone could potentially decrease sodium and water reabsorption, which may not be beneficial for improving renal perfusion in a patient with acute kidney injury.
Choice C reason: Having the patient drink several large glasses of water is not the most effective method for a fluid challenge. Oral intake may not provide the rapid volume expansion needed to improve kidney perfusion, especially in a patient with acute kidney injury where fluid balance and perfusion are critical.
Choice D reason: Instilling 500-1000 mL of normal saline through a nasogastric tube is not an appropriate fluid challenge for promoting kidney perfusion. This method is not typically used for volume expansion in the context of acute kidney injury, as it may not provide the rapid intravascular volume increase needed to enhance renal blood flow.
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