Exhibits
The nurse is reviewing the client's medical record. Select the four findings that require immediate follow-up:
Blood glucose level
Bowel sounds
Blood pressure
Pain level
Electrocardiogram findings
Lung sounds
Troponin T level
Correct Answer : C,D,E,G
C. The blood pressure readings show significant variability (164/80 mm Hg at 1000, 176/82 mm Hg at 1015, and 110/62 mm Hg at 1200). These fluctuations, especially the higher readings, indicate potential instability and require close monitoring and possibly intervention.
D. The client's pain level is described as 7/10 initially (1000) and decreases to 5/10 after nitroglycerin (1200). Although the pain has decreased, ongoing assessment is necessary to ensure it does not worsen or change in nature.
E. The 12-lead electrocardiogram (ECG) shows tachycardia with ST segment elevation and T wave changes, which are indicative of myocardial ischemia or infarction. This finding requires immediate attention as it suggests ongoing cardiac damage.
G. The troponin T level is elevated at 0.40 ng/mL (normal is less than 0.1 ng/mL). Troponin elevation indicates myocardial injury or infarction and confirms the seriousness of the cardiac event. This finding requires immediate attention to assess the extent of myocardial damage and guide further treatment.
Incorrect Choices
A. While it is slightly elevated, it is not significantly outside the normal range and does not suggest immediate danger or require urgent intervention in the context of the acute cardiac issue. However, monitoring blood glucose levels is important for overall management, especially in a client with diabetes mellitus.
B. The assessment of bowel sounds being present in all 4 quadrants is a normal finding and indicates normal gastrointestinal function. While bowel sounds are important for assessing gastrointestinal health, they are not immediately pertinent to the acute cardiac issue described in the scenario.
F. The nurse notes that lung sounds are clear to auscultation in all lobes, which is a normal finding. Clear lung sounds suggest normal respiratory function and do not require immediate attention in the context of the acute cardiac event described.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A A change in level of consciousness (LOC), such as confusion, lethargy, or loss of consciousness, can indicate worsening neurological status. It reflects impaired brain function due to increased pressure on brain tissues.
B. Pupillary changes, such as dilation or asymmetry, can occur due to pressure on the oculomotor nerve (cranial nerve III). Pupillary dilation can be a sign of increased ICP but typically occurs after other neurological changes.
C. Decorticate posturing indicates significant neurological impairment but typically appears after alterations in consciousness.
D. Cheyne-Stokes respirations indicate brainstem involvement and impaired respiratory control but are generally seen later in the progression of neurological deterioration.
Correct Answer is D
Explanation
D. Instructing the client not to bend the affected leg helps prevent accidental dislodgement of the arterial sheath or catheter and reduces the risk of bleeding or hematoma formation at the insertion site.
A While monitoring vital signs is important, doing so once every hour is not specified as a standard post- procedure action.
B. Elevating the head of the bed to a 45° angle and restricting fluid intake are not standard care measures following this procedure and could potentially be contraindicated.
C. This action is not typically necessary following a cardiac catheterization unless there are specific indications such as fluid overload or impaired renal function
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