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You are caring for this team of patients. Which patient is the priority to see first to collect data?

80-year-old male patient with a history of atrial fibrillation with rapid ventricular response whose cardiac monitor shows a heart rate of 92

66-year-old female patient with a newly inserted permanent pacemaker whose cardiac monitor shows a heart rate of 50

72-year-old male patient with an implantable cardiac defibrillator that delivered a shock 4 hours ago whose cardiac monitor shows normal sinus rhythm and a heart rate of 68

78-year-old male patient with chronic atrial fibrillation who is prescribed metoprolol (Toprol) whose cardiac monitor shows a heart rate of 58.

Answer and Explanation

The Correct Answer is B

A.   While atrial fibrillation with a rapid ventricular response requires attention, it is not an immediate concern unless associated with symptoms such as chest pain, shortness of breath, or hemodynamic instability.
B.   A heart rate of 50 in a patient with a newly inserted permanent pacemaker may indicate bradycardia, which could be a sign of pacemaker malfunction or lead dislodgement. This patient requires immediate assessment to rule out complications.
C.   While recent implantable cardioverter-defibrillator (ICD) discharge warrants evaluation, the patient is currently in normal sinus rhythm with a heart rate of 68, suggesting stability. This patient's assessment can be prioritized after the patient with the pacemaker issue is seen.
D.   A heart rate of 58 in a patient with chronic atrial fibrillation on beta-blocker therapy may not be immediately concerning if the patient is asymptomatic and hemodynamically stable. This patient can be assessed after addressing the more urgent pacemaker issue.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. In the oliguric phase of acute kidney injury, fluid intake may need to be restricted rather than encouraged to prevent fluid overload.
B. Hourly intake and output monitoring is crucial for managing fluid balance and assessing the progression of kidney injury. Close monitoring can help prevent fluid overload, which is a risk due to the reduced urine output. It also aids in the timely adjustment of fluid administration and the detection of any changes in the client's condition that may necessitate intervention.
C. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen are contraindicated in acute kidney injury as they can further impair renal function.

D. In the oliguric phase, protein intake may need to be restricted to reduce the workload on the kidneys and minimize azotemia. A high-protein diet can increase the burden on already compromised kidneys due to the increased production of urea, a byproduct of protein metabolism that requires excretion by the kidneys.

A. Notify the health-care provider. B. Start oxygen at 2 L/min. C. Order an electrocardiogram and cardiac enzymes. D. Place bed in modified Trendelenburg position. E. Allow the patient to rest alone. F. Elevate the head of the bed.

Correct Answer is ["A","B","C","F"]

Explanation

A. Increased premature ventricular contractions along with symptoms of anxiety and shortness of breath may indicate worsening cardiac function or an acute cardiac event, necessitating immediate medical attention.
B. Oxygen therapy may help alleviate symptoms of shortness of breath and improve oxygenation in patients experiencing cardiac symptoms.
C. These diagnostic tests can provide valuable information about cardiac function and any potential myocardial damage or ischemia, helping guide further treatment and management.
D. The modified Trendelenburg position may increase cardiac workload, which is not beneficial in the case of PVCs.
E. The patient should not be left alone due to the need for ongoing assessment and potential rapid intervention. Furthermore, leaving them alone could worsen their anxiety.
F. Elevating the head of the bed can aid in breathing and comfort, reducing the sensation of breathlessness.

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You are caring for this team of patients. Which patient is the priority to see first to collect data?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in the oliguric phase of acute kidney injury. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A patient with a cardiac disorder is having increased premature ventricular contractions and feels "anxious" and short of breath. After vital signs are obtained, what actions should the nurse take? Select all that apply.

Correct Answer is ["A","B","C","F"]

Explanation

A patient is admitted to the hospital for a splenectomy. The nurse understands that the health-care provider prescribes an injection of vitamin K prior to surgery for which action?

A nurse is reinforcing teaching with a client who reports right shoulder pain following a laparoscopic cholecystectomy. Which of the following statements should the nurse make?

The nurse is checking the patency of a new right arm arteriovenous fistula. What action does the nurse use to do this? Select all that apply

A nurse is reviewing the urinalysis results of a client who reports urinary frequency and burning. Which of the following findings should the nurse report to the provider?

The nurse is caring for a patient whose cardiac monitor shows a total absence of electrical impulse as indicated by a flat line. The nurse does not detect a pulse or blood pressure. The nurse would document this as which of the following rhythms?

The nurse is reviewing a patient's electrocardiogram (ECG) tracing. Which of the following are characteristics of normal sinus rhythm (NSR?

The nurse is reading a cardiac monitor of a patient and observes a regular rhythm, and the P waves have a sawtooth pattern. The nurse recognizes this as which arrhythmia?