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 ["A","C","D"]
Explanation
The correct answers are:
A. Oatmeal is a good choice for breakfast.
C. Add lentils and black beans to soups.
D. Increase green leafy vegetables in the diet. Choice A rationale:
Oatmeal is a good choice for breakfast because it is a vegetarian option that is rich in iron. It contains non-heme iron, which is the type of iron found in plant-based foods. Non-heme iron may not be as easily absorbed as heme iron (found in animal products), but it can still contribute to increasing iron levels in the body, especially when combined with other sources of iron.
Choice B rationale:
Eat red meat just until the anemia is resolved is not a suitable instruction for a vegetarian client. Red meat is a source of heme iron, which is not part of a vegetarian diet. While heme iron is more easily absorbed by the body, there are other plant-based sources of iron that can be recommended to the client without compromising their dietary preferences.
Choice C rationale:
Lentils and black beans are excellent choices for a vegetarian client to increase iron intake. Both foods are rich in iron, and they also contain other nutrients that aid in iron absorption, such as vitamin C. Including lentils and black beans in soups can be a tasty and nutritious way to enhance iron intake.
Choice D rationale:
Increasing green leafy vegetables in the diet is another appropriate recommendation for a vegetarian client. Green leafy vegetables, such as spinach and kale, contain non-heme iron, as well as other essential vitamins and minerals that contribute to overall health. Combining them with vitamin C-rich foods can enhance iron absorption.
Choice E rationale:
Take two prenatal vitamins with iron daily is not necessary since the healthcare provider already prescribed one prenatal vitamin with iron daily. Taking additional supplements without medical advice can lead to an excessive intake of certain nutrients, which may have adverse effects on health.
Correct Answer is C
Explanation
The correct answer is Choice C. Soft blanket.
Choice A rationale:
A heating pad should not be applied to the client's legs with a mottled appearance. A mottled appearance indicates poor circulation, and applying heat could potentially worsen the situation by dilating blood vessels and further reducing blood flow to the extremities.
Choice B rationale:
The body lotion is not appropriate in this situation. While it may help moisturize the skin, it will not address the underlying circulation issues causing the mottled appearance. Moreover, applying lotions to areas with compromised circulation can be harmful.
Choice C rationale:
The correct choice. A soft blanket can be applied to the client's legs with a mottled appearance to provide warmth and comfort. It is essential to keep the client comfortable during palliative care, and a soft blanket can help maintain a suitable temperature without causing harm.
Choice D rationale:
Moist clothes are not indicated in this situation. They may potentially worsen the mottled appearance by adding moisture to the skin, and it won't address the circulation issues causing the discoloration.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today