The practical nurse (PN) is caring for a client with coronary artery disease who is admitted with intermittent chest pain. The admission laboratory results indicate elevations in troponin I and creatine phosphokinase myoglobin isoenzyme (CK-MB) levels. What should the PN consider the most significant risk for this client on the second day of admission?
The lab results indicate myocardial damage, and the client is at risk for cardiac dysrhythmias.
The client is at risk for pulmonary embolism, and lifestyle modifications need to be implemented.
The client is at risk for recurrent long-term angina pain and subsequent myocardial infarction (MI).
The lab results indicate risk factors for transient ischemic atack (TIA), and neurological vital signs should be monitored.
The Correct Answer is A
Troponin I and CK-MB are cardiac enzymes that are released into the bloodstream when the heart muscle is injured or necrotic. Elevated levels of these enzymes indicate that the client has suffered a myocardial infarction (MI) or heart attack. The damaged heart tissue can impair the electrical conduction system of the heart and cause abnormal heart rhythms or dysrhythmias, which can be life-threatening. The PN should monitor the client's cardiac status closely and report any changes to the charge nurse.
The other options are not correct because:
B. The client is not at risk for pulmonary embolism, which is a blockage of a pulmonary artery by a blood clot or other material. Pulmonary embolism does not cause elevated cardiac enzymes, but it can cause chest pain, shortness of breath, and hypoxia.
C. The client is not at risk for recurrent long-term angina pain, which is chest pain caused by reduced blood flow to the heart muscle due to narrowed or blocked coronary arteries. Angina pain does not cause elevated cardiac enzymes, but it can be a warning sign of an impending MI.
D. The lab results do not indicate risk factors for transient ischemic attack (TIA), which is a temporary interruption of blood flow to a part of the brain due to a clot or plaque. TIA does not cause elevated cardiac enzymes, but it can cause neurological symptoms such as weakness, numbness, or speech difficulties.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
These are the information that the PN should obtain prior to administering pain medication to an adult postoperative client because they help to assess the client's current pain level, response to previous medication, and need for further intervention. The PN should also document this information in the medical record and report any changes or concerns.
A. Height and weight of client prior to admission are not relevant for administering pain medication and may not affect the dosage or route of the medication.
E. History of pain medication use during the past year is not relevant for administering pain medication and may not indicate the client's tolerance or preference for the medication.
Correct Answer is ["B","D"]
Explanation
The correct answers are Choice B and D:
Choice B: Report the appearance of the dressing to the charge nurse,
Choice D: Compress the drainage device before closing the tab.
Choice A rationale:
Documenting the appearance of the wound as inflamed is not appropriate. As a practical nurse, the immediate concern is to take action and report any concerning findings to the appropriate healthcare provider rather than just documenting it.
Choice B rationale:
Reporting the appearance of the dressing to the charge nurse is essential. The charge nurse or a more experienced healthcare provider needs to be informed of any abnormal findings or signs of infection for further evaluation and appropriate intervention.
Choice C rationale:
Removing the drainage device and applying a pressure dressing is not within the scope of practice for a practical nurse. These actions require a higher level of expertise and are typically performed by a registered nurse or healthcare provider.
Choice D rationale:
Compressing the drainage device before closing the tab is a correct action. This helps to ensure that the device is functioning properly, and there are no leaks or obstructions in the drainage system.
Choice E rationale:
Clamping the drainage tubing for the next four hours is not recommended unless specifically ordered by a healthcare provider. Clamping the drainage tubing without appropriate orders may disrupt the normal drainage process and cause complications.
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