The practical nurse (PN) is caring for a client with coronary artery disease who is admitted with intermittent chest pain. The admission laboratory results indicate elevations in troponin I and creatine phosphokinase myoglobin isoenzyme (CK-MB) levels.

What should the PN consider the most significant risk for this client on the second day of admission?

The lab results indicate myocardial damage, and the client is at risk for cardiac dysrhythmias

The client is at risk for pulmonary embolism, and lifestyle modifications need to be implemented.

The client is at risk for recurrent long-term angina pain and subsequent myocardial infarction (MI).

The lab results indicate risk factors for transient ischemic atack (TIA), and neurological vital signs should be monitored.

Answer and Explanation

The Correct Answer is A

Troponin I and CK-MB are cardiac enzymes that are released into the bloodstream when the heart muscle is injured or necrotic. Elevated levels of these enzymes indicate that the client has suﬀered a myocardial infarction (MI) or heart atack. The damaged heart tissue can impair the electrical conduction system of the heart and cause abnormal heart rhythms or dysrhythmias, which can be life-threatening. The PN should monitor the client's cardiac status closely and report any changes to the charge nurse.

The other options are not correct because:

The client is not at risk for pulmonary embolism, which is a blockage of a pulmonary artery by a blood clot or other material. Pulmonary embolism does not cause elevated cardiac enzymes, but it can cause chest pain, shortness of breath, and hypoxia.
The client is not at risk for recurrent long-term angina pain, which is chest pain caused by reduced blood ﬂow to the heart muscle due to narrowed or blocked coronary arteries. Angina pain does not cause elevated cardiac enzymes, but it can be a warning sign of an impending MI.
The lab results do not indicate risk factors for transient ischemic atack (TIA), which is a temporary interruption of blood ﬂow to a part of the brain due to a clot or plaque. TIA does not cause elevated cardiac enzymes, but it can cause neurological symptoms such as weakness, numbness, or speech difficulties.

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Free Nursing Study Resources

Correct Answer is ["B","D","E"]

Explanation

A. Keeping the battery door closed during storage is generally a good practice to prevent battery drain; however, it may be more appropriate to keep it open for extended storage to avoid moisture buildup. The PN should clarify proper storage practices.
B. Observing and reporting any ear drainage after removing the device is crucial. Any drainage could indicate an infection or other issues that require further evaluation by nursing staff.
C. Storing the device on a windowsill is not advisable, as this increases the risk of loss or damage. A secure, designated storage area is better for such items.
D. Verifying that the device is labeled with the client's identification is important to prevent mix-ups and ensure proper usage. Proper labeling aids in maintaining accountability and safety in a long-term care setting.
E. Removing ear wax from the device's surface is appropriate as it ensures the hearing aid functions properly and maintains hygiene.

A. Monitor the oxygen saturation B. Discuss aggressive respiratory treatment options C. Obtain a sputum culture D. Allow the client to take a position of comfort E. Discuss with the client potential asthma triggers F. Consider positive pressure ventilation G. Wean the supplemental oxygen H. Prepare for deep tracheal suctioning

Correct Answer is ["A","D","E"]

Explanation

A) Correct- Continuous monitoring of oxygen saturation ensures the client's oxygen levels remain within an acceptable range.
B) Incorrect - Discussing aggressive respiratory treatment options is not warranted based on the provided information. The current treatment plan includes appropriate interventions.
C) Incorrect - Obtaining a sputum culture is important for identifying infections, but it's not an immediate action in the context of the client's current symptoms.
D) Correct- Promoting comfort can help reduce anxiety and potentially improve breathing.
E) Correct- Educating the client about potential triggers supports better self-management.
F) Incorrect - Considering positive pressure ventilation is not indicated at this stage. The client's symptoms are being managed with other interventions.
G) Incorrect - Weaning supplemental oxygen is not mentioned in the patient data or nurses' notes as something that's currently necessary.
H) Incorrect - Preparing for deep tracheal suctioning is not warranted based on the patient data and the current treatment plan.

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Naxlex Comprehensive Predictor Exams

The practical nurse (PN) assigns an unlicensed assistive personnel (UAP) to clean the hearing aid of an older adult resident of a long-term care facility. Which instructions should the PN provide to the UAP? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

Find patient data below. Exhibits here What actions should the nurse plan for the rest of the shift? Select all that apply.

Correct Answer is ["A","D","E"]

Explanation

The practical nurse (PN) is caring for a client whose urine drug screen is positive for cocaine. Which behavior is most likely seen in this client?

When the practical nurse (PN) attempts to assist an 18-year-old client with a mild mental disability to ambulate on the first postoperative day after an appendectomy, she becomes angry and says, "PN, 'Get out of here! I'll get up when I'm ready!" Which response is best for the PN to make?

The nurse enters the room of a client with Parkinson's disease who is taking carbidopa-levodopa. The client is rising slowly from the chair while the unlicensed assistive personnel (UAP) stands next to the chair. Which action should the nurse take?

Prior to an invasive examination of a hospitalized client, a consent form should be obtained. Which action best describes the responsibility of the practical nurse (PN)?

The nurse is managing 4 clients in the intensive care unit who are mechanically ventilated. After performing a quick visual assessment, the nurse should prioritize care for the client who is exhibiting which finding.

At a prenatal visit, a primigravida client confides to the practical nurse (PN) that her partner is abusive. Which information should the PN provide?

A client is receiving mesalamine 800 mg by mouth three times a day. Which assessment should the nurse perform to assess the effectiveness of the medication?