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A nurse is caring for a client who has COPD.

Medication

Indacaterol 75 mcg, one inhalation daily

Acetylcysteine 20% solution 3 to 5 ml nebulizer every 6 to 8 hr while awake

Select the 5 findings that require follow-up.

Disorientation

Barrel-shaped chest

Yellow sputum

Nebulizer use

Ankle edema

SaO2 92%

Clubbing of fingers

Answer and Explanation

Correct Answer : A,B,C,E,F

A. Disorientation:

This may indicate a neurological or cognitive issue and requires further assessment.

B. Barrel-shaped chest:

This is a characteristic finding in COPD, but any change or worsening may need evaluation.

C. Yellow sputum:

Yellow or greenish sputum may indicate an infection, and follow-up is needed.

D. Nebulizer use:

Nebulizer use is part of the prescribed treatment.

E. Ankle edema:

Edema can be a sign of heart failure or other cardiovascular issues and should be investigated.

F. SaO2 92%:

Oxygen saturation of 92% is below the normal range. It may indicate respiratory compromise and needs attention.

G. Clubbing of fingers:

While clubbing can be associated with chronic respiratory conditions, it is not an immediate concern.

H. Lives alone:

Living alone may impact the client's support system but does not require immediate medical attention.

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Correct Answer is A

Explanation

A. "These tests help determine the degree of damage to the heart tissues." - This is the correct statement. Cardiac enzyme studies, such as creatine kinase (CK), CK-MB, troponin I, and troponin T, are used to assess the extent of myocardial damage during an acute myocardial infarction (MI). Elevated levels of these enzymes indicate myocardial injury and help healthcare providers determine the severity of the heart tissue damage.

B. "Cardiac enzymes will identify the location of the MI." - While cardiac enzymes can confirm the presence of an MI, they do not specifically identify the location of the infarction. Other diagnostic tools, such as electrocardiogram (ECG) and imaging studies, may help determine the location of the MI.

C. "Cardiac enzymes assist in diagnosing the presence of pulmonary congestion." - Cardiac enzymes are not used to diagnose pulmonary congestion. Other diagnostic methods, such as chest X-rays and physical examination, are more appropriate for assessing pulmonary congestion.

D. "These tests will enable the provider to determine the heart structure and mobility of the heart valves." - Cardiac enzyme studies do not provide information about the overall heart structure or the mobility of heart valves. Imaging studies, such as echocardiography, are used for this purpose.

A. Troponin is a lipid whose levels reflect the risk for coronary artery disease. B. Troponin is an enzyme that indicates damage to brain, heart, and skeletal muscle tissues. C. Troponin is a protein that helps transport oxygen throughout the body. D. Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart

Correct Answer is D

Explanation

A. Troponin is a lipid whose levels reflect the risk for coronary artery disease: This statement is incorrect. Troponin is not a lipid, and its levels do not reflect the risk for coronary artery disease. Troponin is a protein associated with muscle tissue.

B. Troponin is an enzyme that indicates damage to brain, heart, and skeletal muscle tissues: While troponin indicates damage to muscle tissues, it is specifically associated with cardiac muscle, not brain or skeletal muscle tissues.

C. Troponin is a protein that helps transport oxygen throughout the body: This statement is incorrect. While proteins in the blood may contribute to oxygen transport, troponin's primary role is in muscle contraction, particularly in the heart.

D. Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart: This is the correct answer. Troponin is a protein found in cardiac muscle cells, and when there is damage to the heart, such as during a myocardial infarction, troponin is released into the bloodstream. Elevated troponin levels in the blood are indicative of myocardial injury or infarction.

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A nurse is caring for a client who has COPD. Medication Indacaterol 75 mcg, one inhalation daily Acetylcysteine 20% solution 3 to 5 ml nebulizer every 6 to 8 hr while awake Select the 5 findings that require follow-up.

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Naxlex Comprehensive Predictor Exams

A nurse is teaching the partner of a client who had an acute myocardial infarction (MI) about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzymes studies?

Correct Answer is A

Explanation

Correct Answer is D

Explanation

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A nurse is caring for a client who the provider suspects might have pernicious anemia. The nurse should expect the provider to prescribe which of the following diagnostic tests?

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A nurse is caring for a client who has COPD.

Medication

Indacaterol 75 mcg, one inhalation daily

Acetylcysteine 20% solution 3 to 5 ml nebulizer every 6 to 8 hr while awake

Select the 5 findings that require follow-up.