NCLEX Practice Test

Which client should the nurse assess first in a cardiac intensive care unit?

1. Client 2 months post heart transplant with sustained sinus tachycardia of 110/min at rest

2. Client 3 hours post coronary artery stent placement with severe back pain

3. Client receiving IV antibiotics for infective endocarditis with a temperature of 101.5 F (38.6 C)

4. Client who had coronary bypass graft surgery 3 days ago with swelling in the leg used for the donor graft

The correct answer is: Client 3 hours post coronary artery stent placement with severe back pain

In a cardiac intensive care unit, the priority for assessment generally involves any signs or symptoms that could indicate a life-threatening complication. The client who is three hours post coronary artery stent placement with severe back pain requires immediate attention due to the risk of complications such as hematoma formation, arterial occlusion, or vascular injury, which can lead to serious outcomes if not promptly addressed. Severe back pain in this context may also suggest cardiac complications or a vascular issue related to the procedure, making it critical for the nurse to evaluate this client first. This prioritization considers not only the timing of the procedure but also the severity of the symptom being reported. The acute nature of the severe back pain raises immediate concerns that could compromise the client's well-being, warranting swift assessment and intervention.