Author Question: After receiving the following information about four patients during change-of-shift report, which ... (Read 24 times)

nummyann · **on:** Jun 25, 2018

After receiving the following information about four patients during change-of-shift report, which patient should the nurse assess first?

a. Patient with acute pericarditis who has a pericardial friction rub
b. Patient who has just returned to the unit after balloon valvuloplasty
c. Patient who has hypertrophic cardiomyopathy and a heart rate of 116
d. Patient with a mitral valve replacement who has an anticoagulant scheduled

Question 2

After receiving report on the following patients, which patient should the nurse assess first?

a. Patient with rheumatic fever who has sharp chest pain with a deep breath
b. Patient with acute aortic regurgitation whose blood pressure is 86/54 mm Hg
c. Patient with infective endocarditis who has a murmur and splinter hemorrhages
d. Patient with dilated cardiomyopathy who has bilateral crackles at the lung bases

Meganchabluk · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: B
The patient who has just arrived after balloon valvuloplasty will need assessment for complications such as bleeding and hypotension. The information about the other patients is consistent with their diagnoses and does not indicate any complications or need for urgent assessment or intervention.

Answer to Question 2

ANS: B
Hypotension in patients with acute aortic regurgitation may indicate cardiogenic shock. The nurse should immediately assess this patient for other findings such as dyspnea or chest pain. The findings in the other patients are typical of their diagnoses and do not indicate a need for urgent assessment and intervention.