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.

Answer and Explanation

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 atack. 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:

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.
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.
The lab results do not indicate risk factors for transient ischemic atack (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.

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Correct Answer is C

Explanation

it provides reality orientation and helps the client cope with the change in environment. The client may be experiencing acute confusion or delirium due to stress, medication, infection, or other factors. The PN should remind the client of the date, time, and place frequently and use other strategies such as calendars, clocks, and familiar objects to reduce confusion.

A. A 12-year-old child with history of asthma who is wheezing and complaining of shortness of breath. B. A 7-year-old child who has type 1 diabetes mellitus and is experiencing extreme hunger and shakiness. C. A 10-year-old child with bleeding lacerations on both knees after falling on the playground. D. A 5-year-old child who is crying uncontrollably because of an incontinent bowel episode.

Correct Answer is A,B,C,D

Explanation

This client has the highest priority, as he or she may be experiencing an acute asthma attack that can compromise the airway and oxygenation. The PN should assess the client's respiratory status, administer bronchodilators, and monitor for improvement or deterioration.

B. A 7-year-old child who has type 1 diabetes mellitus and is experiencing extreme hunger and shakiness.

This client has the second highest priority, as he or she may be experiencing hypoglycemia, which is a low blood glucose level that can cause neurologic symptoms such as confusion, seizures, or coma. The PN should check the client's blood glucose level, provide a source of glucose, and monitor for recovery or complications.

C. A 10-year-old child with bleeding lacerations on both knees after falling on the playground.

This client has the third highest priority, as he or she may have a risk of infection or blood loss from the wounds. The PN should clean and dress the lacerations, apply pressure if needed, and check for signs of infection or inﬂammation.

D. A 5-year-old child who is crying uncontrollably because of an incontinent bowel episode.

This client has the lowest priority, as he or she does not have a life-threatening or urgent condition, but a psychosocial or emotional issue. The PN should provide comfort and reassurance to the child, change his or her clothes, and explore the possible causes of the incontinence.

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Naxlex Comprehensive Predictor Exams

An older female adult who was admited to a long-term care facility yesterday is confused about what day of the week it is. Her history does not indicate that she was confused prior to admission. What action should the practical nurse (PN) take?

Correct Answer is C

Explanation

Correct Answer is A,B,C,D

Explanation

Find patient data about a client below. After the nurse assesses the client, the physician writes orders. The nurse reviews the orders. Which 2 orders should the nurse complete first?

A 4-month-old infant is brought to the clinic by a parent with symptoms of a runny nose, a slight fever, and cough for the last two days Which finding should alert the nurse that the child is in acute respiratory distress?

The charge nurse brings a #18 urinary catheter with a 30 mL balloon to the practical nurse (PN) who is preparing to insert a catheter in a female client who weighs 50 kg. Which action should the PN take first?

The nurse identifies an electrolyte imbalance, elevated blood pressure, and exhibited changes in mental status for a client with chronic kidney disease. Which is the most important action for the nurse to take?

A chronically depressed older male resident of a long-term care facility has become more reclusive and today refuses to leave his room. His family has moved away and are unable to visit as much as in the past. Which comment by the practical nurse (PN) is likely to be most helpful to this client?

The practical nurse (PN) is caring for a client whose urine drug screen is positive for cocaine. Which behavior is most likely seen in this client?

Patient Data Exhibits Which 3 responses should the diabetic nurse educator provide?