A nurse is providing care for a client who experienced a myocardial infarction prior to a cardiac arrest. Which of the following laboratory tests will identify early injury to the cardiac muscle?

Creatine kinase (CK) test

Creatine kinase-myocardial band (CK-MB) test

Brain natriuretic peptide (BNP) test

Troponin T test

Answer and Explanation

The Correct Answer is D

Answer: D. Troponin T test

Rationale:

A. Creatine kinase (CK) test: While creatine kinase isoenzymes, including CK-MB, can be elevated following myocardial infarction (MI), they are not specific to cardiac muscle injury. CK is found in various tissues throughout the body, so elevated levels can also indicate damage to skeletal muscle or brain tissue, among other sources.

B. Creatine kinase-myocardial band (CK-MB) test: CK-MB is a cardiac-specific isoform of creatine kinase, and elevated levels can indicate myocardial injury, particularly in the context of an acute MI. However, troponin T is a more sensitive and specific marker for myocardial injury.

C. Brain natriuretic peptide (BNP) test: Brain natriuretic peptide is primarily used in the diagnosis and management of heart failure. While elevated BNP levels can indicate heart muscle strain or stress, they are not specific markers for acute myocardial infarction or early injury to the cardiac muscle.

D. Troponin T test: This is the correct answer. Troponin T is a highly specific marker for cardiac muscle injury. Elevated troponin levels can be detected within hours of myocardial infarction and persist for several days, making it an essential tool in the diagnosis of acute coronary syndromes, including myocardial infarction. Troponin T is considered one of the gold standard biomarkers for detecting early injury to the cardiac muscle.

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Correct Answer is A

Explanation

When updating protocols for the use of belt restraints, the nurse manager should include the following guideline:

A) Document the client’s condition every 15 min

Frequent documentation of the client's condition and the need for restraint is essential to monitor their well-being and ensure that restraints are used only when necessary. The other options are not recommended:

B) Requesting a PRN restraint prescription for clients who are aggressive is not appropriate because restraints should only be used when there is an immediate risk to the patient or others, and obtaining a PRN prescription for restraints is generally not standard practice.

C) Attaching the restraint to the bed's side rails is not recommended because restraints should be used as a last resort, and there are specific guidelines for restraint application to ensure patient safety.

D) Removing the client's restraint every is not appropriate either. Restraints should only be removed when the client's condition improves, and alternatives to restraint have been explored, or when it's deemed necessary for the patient's safety and well-being following established protocols and guidelines. The option seems incomplete and does not specify the appropriate time frame for removal.

A. Administer epinephrine subcutaneously. B. Place the blood bag in a biohazard bag before discarding. C. Document the reaction in the medical record. D. Infuse 500 ml lactated Ringer's IV.

Correct Answer is C

Explanation

Choice A reason:

Administer epinephrine subcutaneously. This is not the necessary action to be taken. Epinephrine is used to treat severe allergic reactions (anaphylaxis). However, in this case, the client is experiencing a febrile non-haemolytic transfusion reaction, not an allergic reaction.

Choice B reason:

Place the blood bag in a biohazard bag before discarding. This is not the necessary action to be taken by the nurse. Proper disposal of biohazardous materials is essential, but in this situation, the nurse's priority is to address the client's condition and not the disposal of the blood bag

Choice C reason:

Documentation of the transfusion reaction is crucial for the client's medical history and for future reference. The nurse should record the client's signs and symptoms, the actions taken, and any other relevant information related to the reaction.

Choice D reason

Infuse 500 ml lactated Ringer's IV. This is not necessary action to be taken by the nurse because there is no indication for infusing lactated Ringer's solution in response to the transfusion reaction described. Treatment for febrile non-haemolytic transfusion reactions generally involves stopping the transfusion, administering antipyretics (like acetaminophen) if necessary, and providing supportive care as needed.

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A nurse is providing care for a client who experienced a myocardial infarction prior to a cardiac arrest. Which of the following laboratory tests will identify early injury to the cardiac muscle?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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