A nurse is caring for a client who has angina.
Complete the following sentence by using the lists of options.
The client is at risk for developing
The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}
- Myocardial infarction: The rising troponin levels (Troponin T increasing from 0.08 ng/mL to 0.2 ng/mL and Troponin I rising from 0.01 ng/mL to 0.1 ng/mL) indicate myocardial injury. Persistent chest tightness, shortness of breath, diaphoresis, and anxiety suggest ongoing ischemia. The lack of complete pain relief after nitroglycerin further supports myocardial infarction rather than stable angina.
- Pulmonary embolism: Shortness of breath is a symptom of pulmonary embolism, but the absence of acute hypoxia, pleuritic chest pain, or significant coagulation abnormalities makes this less likely. The client's symptoms and laboratory findings more strongly support a cardiac etiology.
- Bleeding: While thrombolytic therapy increases bleeding risk, the aPTT (32 seconds) and platelet count (350,000/mm³) are within normal limits. There are no reported signs of active bleeding, such as hypotension, bruising, or hematuria, making this a less relevant immediate concern.
- Shortness of breath: Often present in myocardial infarction due to decreased cardiac output and pulmonary congestion. The combination of chest pain, diaphoresis, and dyspnea suggests worsening ischemia rather than a primary pulmonary process. However, it is a nonspecific symptom that can also indicate pulmonary embolism or respiratory distress.
- aPTT levels: Normal at 32 seconds (reference: 30–40 seconds), which suggests no immediate risk of abnormal clotting or excessive anticoagulation. This finding does not directly indicate myocardial infarction but is important in monitoring bleeding risk with thrombolytic therapy. A significantly elevated aPTT could raise concern for hemorrhagic complications.
- Elevated troponin levels: A highly specific marker for myocardial injury. The rise in Troponin T and Troponin I over time confirms myocardial damage, distinguishing acute coronary syndrome from stable angina. This trend is critical in diagnosing myocardial infarction, as troponin elevation correlates with the extent of cardiac muscle injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Wears an N95 mask when providing wound care: MRSA is transmitted via direct contact rather than airborne particles, so an N95 mask is unnecessary unless the client has a secondary airborne infection like tuberculosis. Standard contact precautions, including gloves and gowns, are sufficient to prevent transmission.
B. Wears clean gloves when caring for the client: MRSA requires contact precautions, which include wearing gloves when touching the client or contaminated surfaces. Gloves help prevent the spread of bacteria, particularly from wound drainage, body fluids, or contaminated equipment.
C. Remains 3 feet away from the client: MRSA does not require droplet precautions, which would necessitate maintaining a distance of 3 feet. Instead, direct skin-to-skin contact or contact with contaminated surfaces is the primary mode of transmission, requiring gloves and gowns rather than distance.
D. Disposes of isolation gown outside of the client's room: Isolation gowns should be removed inside the client’s room to prevent cross-contamination. Removing the gown before exiting the room reduces the risk of spreading MRSA to other areas and healthcare personnel.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"C"}}
Explanation
Anticipated:
- Metoprolol 5 mg every 2 to 3 min up to three doses
- Oxygen at 2 L/min via nasal cannula
- Draw electrolytes along with Hgb and Hct
- Morphine 6 mg IV bolus every 3 hr as needed for pain
- Nitroglycerin 0.4 mg SL now may repeat every 5 min up to 3 doses
Nonessential:
- Obtain daily weight
Contraindicated:
- Atropine 0.5 mg IV bolus every 5 min up to 2 mg
Rationale:
- Metoprolol 5 mg every 2 to 3 min up to three doses: Beta-blockers reduce myocardial oxygen demand by decreasing heart rate and blood pressure, making them beneficial in acute coronary syndrome. They should be used cautiously in patients with signs of heart failure or bradycardia.
- Oxygen at 2 L/min via nasal cannula: Supplemental oxygen is recommended for clients with acute coronary syndrome when oxygen saturation is below 94% to optimize myocardial oxygen supply and prevent ischemia.
- Draw electrolytes along with Hgb and Hct: Electrolytes are critical in evaluating myocardial function, and hemoglobin/hematocrit levels help assess perfusion and oxygen-carrying capacity.
- Morphine 6 mg IV bolus every 3 hr as needed for pain: Morphine is used to relieve severe chest pain in myocardial infarction and reduce myocardial oxygen demand by decreasing anxiety and preload.
- Nitroglycerin 0.4 mg SL now may repeat every 5 min up to 3 doses: Nitroglycerin dilates coronary arteries, improving oxygen delivery to the myocardium, and reduces preload and afterload, alleviating chest pain. It is a first-line treatment for angina and myocardial infarction but should be avoided in cases of hypotension.
- Obtain daily weight: Daily weight monitoring is primarily used for fluid balance assessment in conditions like heart failure rather than for acute myocardial infarction management.
- Atropine 0.5 mg IV bolus every 5 min up to 2 mg: Atropine is used to treat bradycardia. However, the client is tachycardic, so atropine would worsen the condition and is contraindicated.
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