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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Shortness of breath is a heart failure symptom, not a furosemide side effect, which causes diuresis. Lightheadedness from hypotension is common, making this incorrect, as it confuses disease symptoms with medication effects in the nurse’s monitoring plan for furosemide.
Choice B reason: Lightheadedness is a common furosemide adverse effect due to hypotension or electrolyte imbalances from diuresis. This aligns with pharmacological monitoring for heart failure treatment, making it the correct effect the nurse should plan to monitor in the client.
Choice C reason: Dry cough is associated with ACE inhibitors, not furosemide, a diuretic causing hypotension. Lightheadedness is a furosemide effect, making this incorrect, as it misattributes a side effect to the wrong medication in the nurse’s monitoring for heart failure treatment.
Choice D reason: Bitter taste is not a typical furosemide side effect; it’s more linked to medications like antibiotics. Lightheadedness is relevant, making this incorrect, as it does not reflect the expected adverse effects the nurse should monitor with furosemide administration.
Correct Answer is C
Explanation
Choice A reason: Rolling down tight stockings creates a tourniquet effect, worsening venous insufficiency. Elevating feet improves circulation, making this incorrect, as it reflects a misunderstanding of compression therapy compared to the correct management taught by the nurse for venous insufficiency.
Choice B reason: Putting on stockings after swelling begins is less effective than wearing them preventatively. Elevating feet reduces edema, making this incorrect, as it shows partial understanding compared to the proactive elevation strategy indicating full comprehension of the nurse’s teaching.
Choice C reason: Elevating feet when sitting promotes venous return, reducing edema in venous insufficiency. This aligns with self-care education for the condition, making it the correct statement, as it demonstrates the client’s accurate understanding of the nurse’s teaching to manage lower extremity swelling.
Choice D reason: Crossing legs impairs venous return, exacerbating venous insufficiency, regardless of duration. Elevating feet is correct, making this incorrect, as it reflects a misconception about safe practices compared to the nurse’s teaching on managing venous insufficiency effectively.
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