A nurse is caring for a client who has angina.

Exhibits

Complete the following sentence by using the lists of options.

The client is at risk for developing
dropdown
due to
dropdown
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Rationale for Correct Answers:

Myocardial infarction: The client's worsening chest pain and increasing troponin levels strongly indicate myocardial injury. Despite initial nitroglycerin, symptoms persisted, and thrombolytic therapy was started, consistent with acute MI management.
Troponin levels: Troponin T rose from 0.08 to 0.2 ng/mL, and Troponin I from 0.01 to 0.1 ng/mL, exceeding the normal range. These cardiac biomarkers are sensitive indicators of myocardial cell damage, confirming the progression toward infarction.

Rationale for Incorrect Choices:

Bleeding: Although thrombolytics and aPTT monitoring are related to bleeding risks, there is no current evidence of bleeding (e.g., hematuria, bruising, low platelets, or elevated aPTT). Platelets and aPTT are within normal ranges, so this is not the primary concern at this time.
Pulmonary embolism: The client is short of breath and diaphoretic, which could be seen in PE, but there is no indication of risk factors like immobility, recent surgery, or DVT symptoms. Elevated troponins and anginal symptoms more clearly support a cardiac rather than embolic cause.
Shortness of breath: While SOB is a significant clinical symptom, it is nonspecific and could result from anxiety, cardiac ischemia, or pulmonary causes. It does not directly confirm the most urgent diagnosis, which is best supported by objective lab data such as troponins.
aPTT levels: The aPTT is within the expected therapeutic range and does not indicate a coagulation problem at this time. It is not a primary driver of the client's current risk status, especially in comparison to the elevated cardiac markers.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. "Place the mouthpiece in your mouth and inhale slowly.": This is the correct technique for using an incentive spirometer. Slow, deep inhalation through the mouthpiece promotes lung expansion and helps prevent atelectasis, especially after surgery or prolonged immobility.
B. "Remove the mouthpiece and exhale quickly.": Exhaling quickly is not part of incentive spirometry use and can negate the benefits of the deep inhalation. The focus should be on slow inhalation to expand the lungs gradually and effectively.
C. "Use the incentive spirometer every 4 hours.": While some protocols may vary, clients are typically instructed to use the incentive spirometer more frequently—often 10 times every hour while awake—to promote optimal lung function and prevent complications like pneumonia.
D. "Avoid coughing during and after the session.": Coughing is encouraged after using the spirometer to help clear secretions that may have mobilized during deep breathing. Suppressing the cough would interfere with respiratory hygiene and lung recovery.

A. Administer flumazenil IV per facility policy to the client. B. Assess the client's bilateral hand grasp strength. C. Place a padded tongue blade at the client's bedside. D. Check the client's bedside glucose level.

Correct Answer is B

Explanation

A. Administer flumazenil IV per facility policy to the client: Flumazenil is a benzodiazepine reversal agent and is only indicated if the client received a benzodiazepine. Slurred speech in this context is more likely neurologic in origin due to stroke risk.
B. Assess the client's bilateral hand grasp strength: Clients in sickle cell crisis are at increased risk for stroke. New onset slurred speech is a neurological symptom, and assessing for other focal deficits like hand grasp strength helps detect stroke early.
C. Place a padded tongue blade at the client's bedside: This is not appropriate stroke management and is outdated seizure care. There is no indication of seizure activity, and tongue blades should never be inserted in a client’s mouth during a seizure.
D. Check the client's bedside glucose level: While hypoglycemia can cause neurologic symptoms, in a client with sickle cell disease and new slurred speech, stroke must be prioritized due to the high risk of cerebral infarction during crisis.

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A nurse is caring for a client who has angina. Exhibits Complete the following sentence by using the lists of options. The client is at risk for developing dropdowndue todropdown.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing education to a client who has a prescription for incentive spirometry. Which of the following instructions should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is caring for a client who is experiencing a sickle cell crisis. During morning care, the assistive personnel alerts the nurse that the client is slurring their speech. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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A nurse is admitting a client who reports chest pain and has been placed on a telemetry monitor. Which of the following should the nurse analyze to determine whether the client is experiencing a myocardial infarction?

A nurse is monitoring a client who has a head injury and is receiving mannitol 25% IV. The nurse should identify that which of the following is an adverse effect of the medication and should be reported to the provider?

A nurse is admitting a client who reports tightness in their chest that radiates to left arm. Exhibits Complete the following sentence by using the lists of options. The nurse should first address the client's dropdownfollowed by the client'sdropdown.

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A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following nursing actions are appropriate? (Select all that apply.)

A nurse is reviewing the results of electrocardiography monitoring for a client who has atrial fibrillation. Which of the following findings should the nurse expect?

A nurse is caring for a client who has angina.

Exhibits

Complete the following sentence by using the lists of options.

The client is at risk for developing
dropdown
due to
dropdown
.