A nurse is caring for a client who has angina.
Complete the following sentence by using the lists of options.
The client is at risk for developing
The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}
- Myocardial infarction: The rising troponin levels (Troponin T increasing from 0.08 ng/mL to 0.2 ng/mL and Troponin I rising from 0.01 ng/mL to 0.1 ng/mL) indicate myocardial injury. Persistent chest tightness, shortness of breath, diaphoresis, and anxiety suggest ongoing ischemia. The lack of complete pain relief after nitroglycerin further supports myocardial infarction rather than stable angina.
- Pulmonary embolism: Shortness of breath is a symptom of pulmonary embolism, but the absence of acute hypoxia, pleuritic chest pain, or significant coagulation abnormalities makes this less likely. The client's symptoms and laboratory findings more strongly support a cardiac etiology.
- Bleeding: While thrombolytic therapy increases bleeding risk, the aPTT (32 seconds) and platelet count (350,000/mm³) are within normal limits. There are no reported signs of active bleeding, such as hypotension, bruising, or hematuria, making this a less relevant immediate concern.
- Shortness of breath: Often present in myocardial infarction due to decreased cardiac output and pulmonary congestion. The combination of chest pain, diaphoresis, and dyspnea suggests worsening ischemia rather than a primary pulmonary process. However, it is a nonspecific symptom that can also indicate pulmonary embolism or respiratory distress.
- aPTT levels: Normal at 32 seconds (reference: 30–40 seconds), which suggests no immediate risk of abnormal clotting or excessive anticoagulation. This finding does not directly indicate myocardial infarction but is important in monitoring bleeding risk with thrombolytic therapy. A significantly elevated aPTT could raise concern for hemorrhagic complications.
- Elevated troponin levels: A highly specific marker for myocardial injury. The rise in Troponin T and Troponin I over time confirms myocardial damage, distinguishing acute coronary syndrome from stable angina. This trend is critical in diagnosing myocardial infarction, as troponin elevation correlates with the extent of cardiac muscle injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
- Increase sources of fiber in the diet: Increasing dietary fiber is important for maintaining bowel health, especially when taking iron supplements, as constipation is a common side effect of iron therapy. A higher fiber intake can help alleviate constipation and promote regular bowel movements.
- Take the medication with a source of vitamin C: Vitamin C enhances iron absorption in the gastrointestinal tract. Clients should be instructed to take ferrous sulfate with vitamin C-rich foods (such as citrus fruits) or beverages (like orange juice) to maximize absorption and improve the effectiveness of the iron supplement.
- Take the medication on an empty stomach: Iron supplements are best absorbed when taken on an empty stomach, ideally 1 hour before or 2 hours after meals. However, if gastrointestinal upset occurs, the client may take the medication with food to minimize discomfort, but this can reduce absorption.
- Take an antacid within 30 min after medication administration: Antacids can interfere with the absorption of iron supplements. Clients should be advised to avoid antacids for at least 2 hours before or after taking iron supplements to ensure proper absorption.
- Increase intake of milk and dairy products: Calcium in milk and dairy products can inhibit iron absorption when consumed simultaneously. Clients should be advised to avoid consuming these products around the time they take their iron supplement for optimal absorption.
Correct Answer is A
Explanation
A. Obtain bottles of warm, sterile 0.9% sodium chloride solution: Evisceration requires immediate coverage of the exposed organs with sterile, saline-moistened dressings to prevent drying and infection. Using warm saline helps maintain tissue viability and minimizes damage.
B. Apply a firm pressure dressing across the client's abdomen: A firm pressure dressing is inappropriate, as it could cause further damage to the eviscerated organs and increase intra-abdominal pressure, leading to ischemia or perforation.
C. Attempt to reinsert the protruding viscera: Reinserting the eviscerated organs is contraindicated due to the high risk of contamination, trauma, and further complications. The nurse should instead protect the organs with moist dressings and prepare the client for emergency surgery.
D. Place the client in left lateral recumbent position: The client should be placed in a low Fowler’s position with knees slightly flexed to reduce tension on the abdominal wound and prevent further protrusion of organs. A left lateral recumbent position does not provide the same benefit.
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