Nokea
A nurse in an emergency department is caring for a client who reports substernal chest pain and dyspnea. The client is vomiting and is diaphoretic. Which of the following laboratory tests are used to diagnose a myocardial infarction? (Select all that apply.)
- A. Troponin I, Troponin T, CPK, Myoglobin
- B. Plasma low-density lipoproteins
- C. White blood cell count
- D. Blood glucose level
Correct Answer: A
Rationale: The correct answer is A. Troponin I, Troponin T, CPK, and Myoglobin are all specific laboratory tests used to diagnose a myocardial infarction. Troponin I and T are cardiac biomarkers released into the bloodstream following myocardial cell injury. Creatine phosphokinase (CPK) is an enzyme found in high concentrations in the heart muscle, and elevated levels indicate myocardial damage. Myoglobin is a protein released from damaged muscle cells, including cardiac muscle. These tests provide crucial information to confirm the diagnosis of a myocardial infarction.
Plasma low-density lipoproteins are not specific for diagnosing a myocardial infarction. White blood cell count is not typically used for diagnosing a myocardial infarction, although it may be elevated in response to inflammation associated with heart damage. Blood glucose level is not specific for diagnosing a myocardial infarction and
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A nurse is assessing a client who reports numbness and pain in his right palm, index finger, and middle finger. The client reports working with a keyboard most of the time while at work. The nurse suspects carpal tunnel syndrome. Which of the following tests should the nurse request that the client perform?
- A. Tinel's sign
- B. Phalen's test
- C. Rinne's test
- D. Romberg test
Correct Answer: B
Rationale: The correct answer is B: Phalen's test. Phalen's test is used to assess for carpal tunnel syndrome by having the client flex the wrists and press the backs of the hands together for 1 minute to compress the median nerve. This test reproduces symptoms in individuals with carpal tunnel syndrome due to increased pressure on the median nerve. Tinel's sign (A) is used to assess for nerve compression, but it is not specific to carpal tunnel syndrome. Rinne's test (C) is used to assess for hearing loss. Romberg test (D) is used to assess for balance and proprioception issues. Choices E, F, and G are not relevant to assessing carpal tunnel syndrome.
A nurse is preparing to initiate a transfusion of packed RBC for a client who has anemia. Which of the following actions should the nurse take?
- A. Check the client's vital signs every 15 min during the transfusion.
- B. Obtain a blood pressure reading every 30 minutes during the transfusion.
- C. Start the transfusion at a rapid rate to improve hemoglobin levels.
- D. Check the client's vital signs every hour during the transfusion.
Correct Answer: A
Rationale: The correct answer is A: Check the client's vital signs every 15 min during the transfusion. This is crucial to monitor for any signs of transfusion reaction, such as fever, chills, or hypotension. Vital signs should be closely monitored initially and then at regular intervals to ensure the client's safety. Checking every 15 minutes allows for early detection and prompt intervention if any adverse reactions occur.
Choice B is incorrect because obtaining a blood pressure reading every 30 minutes is not as frequent as checking vital signs every 15 minutes, which is necessary for early detection of adverse reactions.
Choice C is incorrect as starting the transfusion at a rapid rate can lead to adverse reactions like fluid overload or hemolysis. Transfusions should be started at a slow rate to minimize these risks.
Choice D is incorrect because checking vital signs every hour is not frequent enough to detect early signs of transfusion reactions. Regular monitoring every 15 minutes is recommended for safety.
A nurse receives a unit of packed RBCs from a blood bank and notes that the time is 1130. The nurse should begin the infusion at which of the following times?
- A. As soon as the nurse can prepare the client and the administration set
- B. At 1200
- C. At 1300
- D. At 1400
Correct Answer: A
Rationale: The correct answer is A: As soon as the nurse can prepare the client and the administration set. It is important to start the infusion promptly to maximize the effectiveness of the blood transfusion. Delaying the infusion can lead to potential complications. Options B, C, and D are incorrect because they suggest delayed start times, which can be detrimental to the patient's health. Starting the infusion as soon as possible ensures that the patient receives the necessary blood components in a timely manner.
A nurse is caring for a client who is HIV positive and is one day postoperative following an appendectomy. The nurse should wear a gown as personal protective equipment when taking which of the following actions?
- A. Changing the client's linens
- B. Administering oral medications
- C. Taking vital signs
- D. Completing a dressing change
Correct Answer: D
Rationale: The correct answer is D: Completing a dressing change. When completing a dressing change for a client who is HIV positive and postoperative, the nurse should wear a gown as personal protective equipment to prevent potential exposure to blood or body fluids. This is crucial for infection control and to protect both the nurse and the client.
Choice A: Changing the client's linens does not necessarily require wearing a gown unless there is a risk of exposure to blood or body fluids.
Choice B: Administering oral medications does not require wearing a gown as there is no risk of exposure to blood or body fluids.
Choice C: Taking vital signs also does not require wearing a gown unless there is a possibility of exposure to blood or body fluids during the procedure.
In summary, completing a dressing change involves the risk of exposure to blood or body fluids, hence the need for wearing a gown. Other actions listed do not carry the same level of risk, therefore do not require the use of a gown as personal protective
A nurse in an urgent care center is caring for a client who is having an acute asthma exacerbation. Which of the following actions is the nurse's highest priority?
- A. Administering a nebulized beta-adrenergic
- B. Providing supplemental oxygen
- C. Administering an intravenous corticosteroid
- D. Encouraging the client to use their inhaler
Correct Answer: A
Rationale: The correct answer is A: Administering a nebulized beta-adrenergic. This is the highest priority because it helps to rapidly dilate the bronchioles, improving airflow and oxygenation in the client. This immediate action is crucial in managing an acute asthma exacerbation and can prevent respiratory distress. Providing supplemental oxygen (B) is important but not the highest priority. Administering an intravenous corticosteroid (C) is beneficial for reducing inflammation but takes longer to take effect compared to a beta-adrenergic. Encouraging the client to use their inhaler (D) is helpful, but in an acute exacerbation, a nebulized beta-adrenergic is more effective for immediate relief.