Nokea
The nurse is caring for a client who has sustained a myocardial infarction. Which laboratory test would be increased that is specific to myocardium damage?
- A. CPK-MB
- B. Troponin
- C. Creatinine kinase
- D. Myoglobin
Correct Answer: B
Rationale: Troponin is the most specific marker for myocardial damage, remaining elevated for days post-MI.
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The nurse is caring for a client who was admitted for an exacerbation of congestive heart failure.
• Click to highlight the findings in the nurses' note which indicate that the client is progressing towards discharge.
Nurses Notes
Day 1 - 0900 - The client was ambulated 25 feet and did not tolerate the ambulation reporting dyspnea. Gait was unsteady. Provided education on aerobic exercise and the benefits for heart failure.
Client verbally taught back the education with understanding.
Day 3 - 0915 - The client ambulated 30 feet in the hallway without assistance. Gait was steady. The oxygen saturation after ambulation was 95% on room air. Scheduled furosemide was refused by the client.
Educated the client on the purpose of the medication and its benefits.
Click to highlight the findings in the nurses' note which indicate that the client is progressing towards discharge.
- A. The client was ambulated 25 feet and did not tolerate the ambulation reporting dyspnea.
- B. Gait was unsteady.
- C. Provided education on aerobic exercise and the benefits for heart failure.
- D. The client ambulated 30 feet in the hallway without assistance. Gait was steady.
- E. The oxygen saturation after ambulation was 95% on room air.
- F. Scheduled furosemide was refused by the client.
Correct Answer: C,D,E
Rationale: C: Correct - Education with client understanding indicates progress in self-management. D: Correct - Ambulating 30 feet without assistance and with steady gait shows improved physical tolerance. E: Correct - Oxygen saturation of 95% on room air post-ambulation indicates stable respiratory status. A, B, F: Incorrect - Dyspnea, unsteady gait, and medication refusal suggest ongoing issues, not progress toward discharge.
The nurse has performed a cardiovascular assessment on a client, and while auscultating heart tones, the nurse auscultates a harsh blowing sound. The nurse should document this finding as a
- A. pericardial friction rub.
- B. heart murmur.
- C. normal lub-dub sounds.
- D. S3 heart sound.
Correct Answer: B
Rationale: A harsh blowing sound indicates a heart murmur, caused by turbulent blood flow, often due to valve dysfunction.
Which of the following interventions should the nurse include when teaching clients strategies for preventing cardiovascular disease? Select all that apply.
- A. Encouraging regular physical exercise
- B. Promoting a diet high in saturated fats
- C. Advising smoking cessation
- D. Recommend no more than 5 alcoholic drinks a day
- E. Educating about the importance of regular blood pressure monitoring
- F. Instructing on the importance of regular cholesterol screenings
Correct Answer: A,C,E,F
Rationale: Regular exercise reduces cardiovascular risk. B: Incorrect - High saturated fat diets increase cardiovascular risk. C: Correct - Smoking cessation lowers cardiovascular disease risk. D: Incorrect - Alcohol should be limited to 1-2 drinks per day for men, 1 for women. E: Correct - Blood pressure monitoring detects hypertension early. F: Correct - Cholesterol screenings identify hyperlipidemia for early intervention.
The nurse caring for a client with a history of atrial fibrillation is prescribed dofetilide to control the dysrhythmia. What assessment should the nurse prioritize before administering the medication?
- A. Daily weight
- B. Liver function tests
- C. QT interval on the electrocardiogram (ECG)
- D. Blood urea nitrogen (BUN) and creatinine levels
Correct Answer: C
Rationale: Dofetilide can prolong the QT interval, increasing the risk of torsades de pointes, so monitoring the ECG for QT prolongation is critical.
The nurse is reviewing laboratory data for a client suspected of having a myocardial infarction. The nurse anticipates that the CK-MB isoenzyme will peak within how many hours?
- A. 3 to 6 hours
- B. 1 to 2 hours
- C. 48 to 72 hours
- D. 18 hours
Correct Answer: D
Rationale: CK-MB peaks around 18 hours after a myocardial infarction, indicating myocardial damage.