Nokea
Which cardiac enzyme would the nurse expect to elevate first in a client diagnosed with a myocardial infarction (MI)?
- A. Creatine kinase (CK-MB).
- B. Lactate dehydrogenase (LDH).
- C. Troponin.
- D. White blood cells (WBCs).
Correct Answer: C
Rationale: Troponin (C) rises within 3–4 hours post-MI, making it the earliest marker. CK-MB (A) rises in 4–6 hours, LDH (B) in 24–48 hours, and WBCs (D) are nonspecific.
You may also like to solve these questions
Which assessment finding documented by the nurse provides the best evidence that the client has a bacterial infection?
- A. Chest pain
- B. Dry cough
- C. Fever
- D. Dyspnea
Correct Answer: C
Rationale: Fever is a hallmark of bacterial infection, such as in endocarditis.
When the nurse is about to administer digoxin to a client, the client says, 'I think I need to see the eye doctor. Things seem to look kind of green today.' The nurse takes his vital signs, which are blood pressure = 150/94, pulse = 60 bpm, and respirations = 28. What is the most appropriate initial action for the nurse to take?
- A. Administer the medication and record the findings on his chart
- B. Withhold the digoxin and report to the charge nurse
- C. Request an appointment with the ophthalmologist
- D. Reassure the client that he is having a normal reaction to his medication
Correct Answer: B
Rationale: Visual disturbances, such as seeing a green or yellow halo, are signs of digoxin toxicity. The nurse should withhold the medication and report to the charge nurse for further evaluation.
When providing dietary instructions for this client, which healthful alternative should the nurse recommend?
- A. Wheat toast for white bread
- B. Margarine for butter
- C. Cereal for eggs
- D. Ham for sausage
Correct Answer: C
Rationale: Cereal is a low-cholesterol, heart-healthy alternative to eggs, which are high in cholesterol. Wheat toast and margarine still contain some fats, and ham is high in sodium and fat.
Which assessment finding is the best indication that oxygen therapy is effective?
- A. The client's face is flushed.
- B. Capillary refill is 6 seconds.
- C. The client states, 'I'm feeling better.'
- D. The apical pulse is less bounding.
Correct Answer: C
Rationale: The client's subjective improvement in symptoms indicates effective oxygen therapy.
The nurse has received shift report. Which client should the nurse assess first?
- A. The client diagnosed with coronary artery disease complaining of severe indigestion.
- B. The client diagnosed with congestive heart failure who has 3+ pitting edema.
- C. The client diagnosed with atrial fibrillation whose apical rate is 110 and irregular.
- D. The client diagnosed with sinus bradycardia who is complaining of being constipated.
Correct Answer: A
Rationale: Severe indigestion in CAD (A) may indicate angina or MI, requiring immediate assessment. Edema (B), tachycardia (C), and constipation (D) are less urgent.