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 explaining DIC to a client with septic shock. What should the nurse say?
- A. DIC is caused by abnormal coagulation involving fibrinogen.
- B. DIC is due to a vitamin K deficiency.
- C. DIC is caused by bone marrow suppression.
- D. DIC results from an underactive clotting system.
Correct Answer: A
Rationale: The correct answer is A because Disseminated Intravascular Coagulation (DIC) is characterized by abnormal coagulation involving fibrinogen. In DIC, there is widespread activation of the clotting cascade leading to the formation of microthrombi. This process consumes clotting factors like fibrinogen, leading to bleeding tendencies. Vitamin K deficiency (B) primarily affects the production of clotting factors, but it is not the direct cause of DIC. Bone marrow suppression (C) and an underactive clotting system (D) are not accurate explanations for DIC.
A nurse is caring for a client who is experiencing menopausal symptoms and asks the nurse about menopausal hormone therapy (HT). The nurse should inform the client that HT is not recommended due to which of the following findings in the client's medical history?
- A. History of breast cancer
- B. History of hypertension
- C. History of diabetes
- D. History of osteoarthritis
Correct Answer: A
Rationale: The correct answer is A: History of breast cancer. Menopausal hormone therapy (HT) is contraindicated in women with a history of breast cancer due to the potential risk of hormone-dependent cancer recurrence. Hormones can stimulate the growth of estrogen-sensitive breast cancer cells, increasing the risk of cancer recurrence. Therefore, it is crucial for the nurse to inform the client with a history of breast cancer that HT is not recommended. Choices B, C, and D are not directly contraindications for HT in menopausal clients, as long as these conditions are well-controlled and monitored.
A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate?
- A. Skin grafting will be done to replace damaged tissue.
- B. Large incisions will be made in the eschar to improve circulation.
- C. This is a procedure to remove dead tissue from the burn area.
- D. Escharotomy is the removal of the burned area and will not improve circulation.
Correct Answer: B
Rationale: The correct answer is B: Large incisions will be made in the eschar to improve circulation. Escharotomy involves making incisions through the eschar (dead tissue) to relieve constriction and improve circulation in the burned area. By performing escharotomy, blood flow is restored, reducing the risk of compartment syndrome and tissue necrosis.
Choice A is incorrect because skin grafting is a separate procedure done to replace damaged tissue, not part of an escharotomy. Choice C is incorrect as it describes debridement, not escharotomy. Choice D is incorrect since escharotomy aims to improve circulation rather than remove the burned area entirely.
A nurse is discharging a child who has sickle cell anemia after an acute crisis episode. Which of the following instructions should the nurse include in the teaching?
- A. Offer fluids to your child multiple times every day
- B. Offer fluids only during fever episodes.
- C. Give fluids only if the child asks for them.
- D. Limit fluid intake during a crisis to reduce swelling.
Correct Answer: A
Rationale: The correct answer is A: Offer fluids to your child multiple times every day. This is important in sickle cell anemia to prevent dehydration and promote good blood flow, reducing the risk of sickling and subsequent crisis episodes. Adequate hydration helps maintain the flexibility of red blood cells and prevents them from clumping together. Options B, C, and D are incorrect because limiting fluid intake can lead to dehydration and worsen the symptoms of sickle cell anemia during and after a crisis episode. It is essential to encourage regular fluid intake to keep the child well-hydrated and prevent complications.
A nurse is caring for a client who is receiving cisplatin to treat bladder cancer. After several treatments, the client reports fatigue. Which of the following actions should the nurse take?
- A. Check the results of the client's most recent CBC
- B. Administer a blood transfusion
- C. Offer the client a stimulant medication
- D. Advise the client to reduce physical activity
Correct Answer: A
Rationale: The correct answer is A: Check the results of the client's most recent CBC. Fatigue is a common side effect of cisplatin, which can cause bone marrow suppression leading to anemia. Checking the CBC will help determine if the client is experiencing anemia, which can be managed with appropriate interventions. Administering a blood transfusion (B) should not be done without confirming the need through lab results. Offering a stimulant medication (C) may mask the underlying cause of fatigue. Advising the client to reduce physical activity (D) may not address the root cause of the fatigue.