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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 C

Explanation

A. Jaundice is typically not visible in the webbed areas of the fingers.

B. The nail beds are part of the skin that can show jaundice, but they may also be aﬀected by other factors such as anemia, cyanosis, or nail polish.
C. The hard palate is a part of the oral mucosa that can show jaundice, especially in clients with dark skin tones.
D. This is not an area that the nurse should inspect to monitor for the presence of jaundice in a client who is African American and has cholecystitis. The skin can show jaundice, but it may be difficult to detect in clients with dark skin tones.

A. To reduce risk of infection B. To dry gastric secretions C. To promote postoperative healing D. To correct a clotting problem

Correct Answer is D

Explanation

A. While vitamin K plays a role in immune function, its administration prior to surgery primarily aims to correct potential clotting abnormalities rather than prevent infection.

B. Vitamin K does not affect gastric secretions. Its role in this context is unrelated to gastric function.
C. While vitamin K is involved in various physiological processes, its administration prior to surgery is primarily aimed at preventing bleeding complications by ensuring adequate clotting factor synthesis.
D. Vitamin K is essential for the synthesis of clotting factors in the liver.

Administering vitamin K prior to surgery helps ensure adequate levels of clotting factors, reducing the risk of bleeding during and after the procedure.

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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 collecting data from a client who is African American has cholecystitis. Which of the following areas should the nurse inspect to monitor for the presence of jaundice?

Correct Answer is C

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?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with a client who has recurrent urinary tract infections (UTIs) about prevention measures. Which of the following client statements indicates the need for further teaching?

Which of the following describe the function of the kidneys? Select all that apply.

A nurse is assisting with the plan of care for a client who has leukemia and whose platelet count is 50,000 mm. Which of the following interventions should the nurse include in the plan of care?

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?

A nurse is reinforcing discharge teaching with a client who is postoperative for a traditional cholecystectomy and has a T-tube in place. Which of the following instructions should the nurse include in the teaching?

A nurse is reviewing the laboratory reports for a client who has chronic kidney disease. Which of the following laboratory reports should the nurse expect to find?

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

A nurse is collecting data from a client who has end-stage kidney disease and is waiting for transport to dialysis. Which of the following findings should the nurse expect?