You are the charge nurse on the telemetry unit and are responsible for making patient assignments. Which patient would be appropriate to assign to the float RN from the medical-surgical unit?
The 64-year-old admitted for weakness who has a first-degree heart block with a heart rate of 58 beats/min
The 92-year-old admitted with chest pain who has premature ventricular contractions and a heart rate of 58 beats/min
The 71-year-old admitted for heart failure who is short of breath and has a heart rate of 120 to 130 beats/min
The 88-year-old admitted with an elevated troponin level who is hypotensive with a heart rate of 96 beats/min
The Correct Answer is A
A. The 64-year-old admitted for weakness who has a first-degree heart block with a heart rate of 58 beats/min: This patient is stable, with a mild conduction delay and a slightly low heart rate but no acute symptoms. A float RN from a medical-surgical unit would be able to safely monitor vital signs, assess for changes, and provide routine care.
B. The 92-year-old admitted with chest pain who has premature ventricular contractions and a heart rate of 58 beats/min: This patient is higher risk due to age, symptomatic PVCs, and potential acute coronary syndrome. Close monitoring and rapid response capability are required, making this patient less suitable for a float RN unfamiliar with cardiac-specific interventions.
C. The 71-year-old admitted for heart failure who is short of breath and has a heart rate of 120 to 130 beats/min: Tachycardia with acute dyspnea indicates unstable heart failure requiring frequent assessment, interventions for fluid management, and possible oxygen therapy, which are beyond the comfort level of a float RN from a general medical-surgical unit.
D. The 88-year-old admitted with an elevated troponin level who is hypotensive with a heart rate of 96 beats/min: Elevated troponin and hypotension suggest acute myocardial injury with potential cardiogenic shock. This patient is unstable and requires experienced cardiac nurses for continuous monitoring and rapid intervention, making it inappropriate for a float RN assignment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A 45-year-old with constrictive cardiomyopathy who developed acute dyspnea and agitation about 1 hour before shift change: Acute dyspnea and agitation in a patient with constrictive cardiomyopathy suggest potential cardiogenic pulmonary edema, hypoxia, or acute decompensation. These symptoms indicate immediate hemodynamic instability, making this patient the highest priority for rapid assessment, oxygenation, and intervention.
B. A 26-year-old with heart failure caused by congenital mitral stenosis who is scheduled for balloon valvuloplasty later today: While this patient has a significant cardiac history, the patient is currently stable and preparing for a scheduled procedure. Immediate assessment is not urgent compared with acute respiratory distress in another patient.
C. A 77-year-old who transferred from intensive care 2 days ago after coronary artery bypass grafting and has a temperature of 100.6 degrees F: Mild postoperative fever is common and may indicate an early inflammatory response. While it requires monitoring and potentially intervention if trends increase, it is less urgent than acute dyspnea with agitation.
D. A 56-year-old who had a coronary angioplasty and stent placement yesterday and has complained of occasional chest pain since the procedure: Occasional mild chest pain is important to monitor for post-procedural complications, but unless the pain is severe, persistent, or associated with other alarming signs, it is not as immediately life-threatening as acute respiratory distress in a patient with cardiomyopathy.
Correct Answer is B
Explanation
A. Brachial pulse in the right arm: The brachial pulse in the opposite arm is not directly related to the catheterization site. Assessing the contralateral arm does not provide information about local vascular integrity or complications at the insertion site.
B. Radial pulse in the left arm: After a cardiac catheterization via the left antecubital (brachial) artery, palpating the radial pulse distal to the insertion site assesses arterial patency and perfusion to the hand. A strong, palpable pulse confirms that blood flow has not been compromised by hematoma, thrombus, or arterial spasm.
C. Radial pulse in the right arm: The radial pulse in the contralateral arm does not reflect the condition of the catheterized artery. While general assessment is important, it does not help evaluate local complications from the procedure.
D. Brachial pulse in the left arm: While the brachial pulse is proximal to the insertion site, distal assessment at the radial pulse provides a more sensitive indicator of adequate perfusion and potential arterial compromise following the procedure.
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