A patient reports that he has been having “indigestion” for the last few hours. Upon further review, the nurse suspects the patient is having chest pain. Cardiac biomarkers and a 12-lead electrocardiogram (ECG) are done. What finding is most significant in diagnosing an acute coronary syndrome (ACS) within the first 3 hours?

Inverted T waves.

Peaked T wave.

Elevated troponin I.

Elevated troponin T.

Answer and Explanation

The Correct Answer is C

Choice A reason: Inverted T waves suggest ischemia but are less specific than troponin I, which confirms myocardial damage in ACS. This is incorrect, as it’s not the most significant finding within 3 hours compared to the nurse’s reliance on biomarkers for diagnosis.

Choice B reason: Peaked T waves indicate hyperkalemia, not ACS, which is diagnosed by troponin elevation. This is incorrect, as it’s unrelated to the nurse’s expected finding for acute coronary syndrome within the first 3 hours of symptom onset.

Choice C reason: Elevated troponin I is the most significant finding for ACS, indicating myocardial necrosis within 3 hours. This aligns with diagnostic criteria, making it the correct biomarker the nurse would prioritize to confirm acute coronary syndrome in the client.

Choice D reason: Troponin T is also specific for ACS but rises slightly later than troponin I, which is detectable sooner. This is incorrect, as troponin I is more significant within 3 hours for the nurse’s diagnosis of acute coronary syndrome.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Choice A reason: A respiratory rate of 10 breaths/min with deep breathing is low but less concerning than 8 breaths/min with snoring, indicating potential airway obstruction. Respiratory depression is the primary opioid risk, making this incorrect compared to the more severe respiratory compromise.

Choice B reason: A respiratory rate of 8 breaths/min with snoring suggests severe opioid-induced respiratory depression, a life-threatening side effect requiring immediate intervention. This aligns with opioid safety monitoring, making it the correct patient most likely experiencing a critical opioid adverse effect.

Choice C reason: Elevated blood pressure and heart rate suggest pain or stress, not respiratory depression, the primary opioid danger. A low respiratory rate with snoring is more critical, making this incorrect, as it doesn’t indicate a life-threatening opioid side effect.

Choice D reason: A temperature of 100.5°F and being easily roused suggest mild fever, not respiratory depression. Snoring with a rate of 8 breaths/min is more dangerous, making this incorrect, as it doesn’t reflect a life-threatening opioid effect in the patient.

A. Client whose deep tendon reflexes have become hyperactive. B. Client who displays plantar flexion when the bottom of the foot is stroked. C. Client who consistently demonstrates decortication when stimulated. D. Client whose Glasgow Coma Scale (GCS) has changed from 15 to 10.

Correct Answer is D

Explanation

Choice A reason: Hyperactive reflexes suggest neurological irritability but are less urgent than a GCS drop from 15 to 10, indicating deteriorating consciousness. This is incorrect, as it’s lower priority than the nurse’s focus on a client with a significant neurological decline.

Choice B reason: Plantar flexion (Babinski sign) may indicate neurological issues, but a GCS drop to 10 signals acute deterioration, requiring immediate attention. This is incorrect, as it’s less critical than the nurse’s priority to assess the client with a declining GCS.

Choice C reason: Decortication indicates severe brain injury but, if consistent, is less acute than a GCS drop from 15 to 10, suggesting rapid worsening. This is incorrect, as it’s not the nurse’s first priority compared to the client with acute neurological change.

Choice D reason: A GCS drop from 15 to 10 indicates a significant decline in consciousness, a neurological emergency requiring immediate assessment. This aligns with neurosurgical priorities, making it the correct client for the nurse to prioritize on the unit.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

You are taking care of 4 clients who are receiving opioid analgesics for pain management. Which patient is MOST likely to be experiencing a life-threatening opioid side effect?

Correct Answer is B

Explanation

The nurse has just received a report on a group of clients on the neurosurgical unit. Which client is the nurse’s first priority?

Correct Answer is D

Explanation

The newly licensed RN overhears two nurses talking in the elevator about a client who will lose her leg because of negligence of the staff. Which action by the newly licensed RN would be implemented first?

A nurse is assessing a client. Which of the following manifestations would indicate that the client is in cardiogenic shock? (Select all that apply)

The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of headache and nausea and is extremely restless. Which is the priority nursing action?

A client with peripheral artery disease is suffering from ineffective tissue perfusion. Which of the following would be appropriate outcomes for this nursing diagnosis? (Select all that apply)

The nurse caring for a client with chronic obstructive pulmonary disease (COPD) anticipates which arterial blood gas (ABG) findings?

The nurse provides instructions to a client about measures to treat irritable bowel syndrome (IBS). Which statement by the client indicates a need for further teaching?

In collaboration with the registered dietitian nutritionist (RDN), which foods will the nurse teach a client who is taking a potassium-sparing diuretic to avoid or use cautiously? (Select all that apply)

Which client electrocardiography (ECG) change from baseline will alert the nurse to possible development of hypercalcemia?