Initial testing is complete, and the nurse is reviewing the results.

Choose the most likely options for the information missing from the statement by selecting from the lists of options provided.

The nurse determines that the client has
dropdown
evidenced by ST depression on electrocardiogram and normal
dropdown
level.

Answer and Explanation

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

Rationale for correct choices:

New onset angina: The client presents with chest pain described as pressure and tightness that started during activity (mowing the lawn) and worsened despite rest, which is consistent with unstable or new-onset angina. The ECG shows ST depression, indicating myocardial ischemia without infarction. Normal troponin levels confirm that no myocardial cell death has occurred, differentiating angina from myocardial infarction.
Troponin: Troponin T and I are specific biomarkers for myocardial injury. In this client, troponin levels are within normal limits, indicating that myocardial necrosis has not occurred. This supports the diagnosis of angina rather than myocardial infarction.

Rationale for incorrect choices:

Myocardial infarction: MI typically presents with prolonged chest pain and ST-segment changes on ECG plus elevated troponin, indicating cardiac muscle damage. This client’s troponin levels are normal, making MI unlikely at this time.
Aortic aneurysm: Usually presents with sudden, severe, tearing chest or back pain, often radiating to the back. ST depression on ECG is not associated with aortic aneurysm.
Prothrombin time (PT) or C-reactive protein (CRP): PT assesses coagulation, and CRP is a marker of general inflammation. Neither is specific for myocardial ischemia, so normal levels do not confirm or exclude angina. Troponin is the key biomarker for cardiac injury.

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Free Nursing Study Resources

Correct Answer is "{\"xRanges\":[67.52494131455398,86.30428403755869],\"yRanges\":[37.5,61.30952380952381]}"

Explanation

Rhinorrhea is the drainage of fluid from the nasal cavity. In cases of suspected CSF leak (often after head trauma, skull base fracture, or neurosurgery), CSF can escape through the nose. The nurse would collect fluid from the nares for testing (commonly the halo test or laboratory analysis for glucose or beta‑2 transferrin).

A. Instruct the UAP to notify the nurse of any changes in the client's respiratory status. B. Remind the UAP to apply a fitted respirator mask before entering the client's room. C. Review the need for the UAP to wear a face mask while in close contact with the client. D. Assign the UAP to provide care for another client and assume full care of the client.

Correct Answer is C

Explanation

A. While it is important for the UAP to report changes in the client’s respiratory status, this action does not address the immediate infection control issue related to influenza transmission. It is not the first priority in this scenario.

B. A fitted respirator (e.g., N95) is generally indicated for airborne precautions (e.g., tuberculosis), not for influenza, which is transmitted primarily through droplets. Therefore, instructing the UAP to wear a respirator is unnecessary and not evidence-based for influenza.

C. This is the most appropriate immediate action. Influenza requires droplet precautions, which include wearing a surgical or procedure mask when within close contact of the client (usually within 6 feet). Reviewing proper mask use ensures the UAP is protected and prevents the spread of infection to themselves and others. This addresses the priority safety concern.

D. Reassigning the UAP or taking over care is unnecessary if proper droplet precautions are followed. The UAP can safely assist once masked appropriately, so the nurse should first educate rather than reassign.

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Naxlex Comprehensive Predictor Exams

In caring for a client following a head injury, the nurse plans to assess for rhinorrhea so that a sample can be tested for the presence of cerebrospinal fluid (CSF). At which location should the nurse observe for this finding? (Click the chosen location. To change, click on the new location.)

Correct Answer is "{\"xRanges\":[67.52494131455398,86.30428403755869],\"yRanges\":[37.5,61.30952380952381]}"

Explanation

A client with influenza needs help in transferring to the bedside commode. The nurse observes the unlicensed assistive personnel (UAP) donning gloves and a gown to assist the client. Which action should the nurse take?

Correct Answer is C

Explanation

The nurse is caring for a client who reports running out of aspirin 1 week ago and taking ibuprofen as a replacement. Which information should the nurse obtain from the client first?

An older adult client with dementia who is refusing to allow an unlicensed assistive personnel (UAP) to assist in bathing, is becoming increasingly agitated and states the UAP, "Wants to hurt me and tie me up." Which approach should the nurse use with the client?

An adult client who had a gastric bypass two days ago reports to the nurse of feeling bloated. After verifying that the client's abdomen is distended, which intervention should the nurse implement?

An older client with an acute attack of gouty arthritis receives a prescription for indomethacin 50 mg PO three times a day. The client prefers an oral suspension which is available 5 mg/mL. How many mL should the nurse administer each day? (Enter numerical value only.)

A female client sustains a deep partial-thickness burn covering more than 40% of her body. Which physiological response should the nurse anticipate during the acute phase of burn injury?

The nurse administers morphine to a client for chest pain who also has obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client alone?

The nurse administers insulin aspart to the client with type 2 diabetes at 0830 and delivers the breakfast tray. When the nurse picks up the tray at 0900, only half the meal has been consumed. Which time is the client at highest risk for hypoglycemia?