The nurse has finished reviewing the shift report on a cardiac unit. The nurse should plan to see which of the following assigned clients first?

Correct Answer: C

Rationale: The correct answer is C. The client receiving antibiotics for bacterial endocarditis reporting anxiety and chest pain should be seen first. This client is at risk for complications like infective endocarditis, which can lead to serious cardiac issues. Addressing the anxiety and chest pain promptly is essential to prevent further deterioration. A client with hypertrophic cardiomyopathy reporting dyspnea may need attention next, but it's not as urgent as addressing a potential complication like infective endocarditis. The client post-cardiac catheterization ambulating for the first time and the client recovering from CABG with a fever of 101 F can be seen after the client with bacterial endocarditis due to the acuity of their presenting symptoms.

Correct Answer: D

Rationale: The correct answer is D: Troponin. Troponin is a cardiac-specific biomarker released into the bloodstream following myocardial injury, making it the most sensitive and specific marker for detecting acute myocardial infarction. It rises rapidly within hours of the infarction and remains elevated for several days, providing a reliable indication of recent heart damage. LDH (choice A), CK-MM (choice B), and SGOT (choice C) are also cardiac enzymes, but they lack the cardiac specificity and sensitivity of Troponin for detecting acute myocardial infarction. LDH and CK-MM are less specific and slower to rise, while SGOT is found in other tissues besides the heart, leading to lower diagnostic accuracy compared to Troponin.

Correct Answer: B

Rationale: The absence of "P" waves suggests the impulse is not originating from the sinus node (A). In a junctional rhythm (B), the impulse originates from the AV node, resulting in the absence of "P" waves. Atrial fibrillation (C) would show irregularly spaced "P" waves due to chaotic atrial activity. A ventricular rhythm (D) would have widened QRS complexes without preceding "P" waves. Thus, based on the absence of "P" waves and normal other components, a junctional rhythm is the most likely explanation.

Correct Answer: B

Rationale: The correct answer is B: Beck's triad. Beck's triad consists of hypotension, distended neck veins, and muffled heart sounds, which are classic signs of cardiac tamponade. Hypotension results from decreased cardiac output due to compression of the heart by the fluid in the pericardial sac. Distended neck veins occur due to increased venous pressure from impaired right heart filling. Muffled heart sounds are heard because the fluid around the heart dampens sound transmission. Shortness of breath (Choice A) is a non-specific symptom and can be present in various cardiac conditions. Holosystolic murmur (Choice C) and bounding peripheral pulse (Choice D) are not characteristic of cardiac tamponade.

Correct Answer: B

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.