a client is admitted with a possible myocardial infarction which laboratory test result is most indicative of a myocardial infarction
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Nursing Elites

HESI RN

HESI 799 RN Exit Exam

1. A client is admitted with a possible myocardial infarction. Which laboratory test result is most indicative of a myocardial infarction?

Correct answer: B

Rationale: Serum troponin is the most specific and sensitive indicator of myocardial infarction. Troponin levels rise within 3-4 hours after myocardial damage, peak at 10-24 hours, and remain elevated for up to 10-14 days. Creatine kinase (CK) and myoglobin can also be elevated in myocardial infarction, but troponin is more specific to cardiac muscle damage. C-reactive protein (CRP) is a marker of inflammation and is not specific for myocardial infarction.

2. A client is admitted with a diagnosis of septic shock. Which clinical finding requires immediate intervention?

Correct answer: C

Rationale: In a client with septic shock, a heart rate of 120 beats per minute is a critical clinical finding that requires immediate intervention. A rapid heart rate can indicate worsening sepsis and inadequate tissue perfusion. Correcting the underlying cause of the tachycardia and stabilizing the heart rate is crucial in managing septic shock. The other options, while important, do not represent an immediate threat to the patient's condition. A blood pressure of 90/60 mmHg may be expected in septic shock, a temperature of 100.4°F is mildly elevated, and a urine output of 30 ml/hour, though decreased, may not be an immediate concern in the context of septic shock.

3. A male client is prescribed clozapine (Clozaril), an antipsychotic medication, for the management of schizophrenia. Which client history should the nurse report to the healthcare provider before administering the first dose of this medication?

Correct answer: B

Rationale: The correct answer is B: History of cardiac arrhythmia. Clozapine can lead to severe cardiovascular problems, making it crucial to report any history of cardiac arrhythmia to the healthcare provider before administering the medication. Choices A, C, and D are less concerning in this context as they are not directly associated with potential serious complications related to clozapine use.

4. The nurse is preparing to administer an enema to a client with severe constipation. Which position is most appropriate for the client?

Correct answer: C

Rationale: Sims’ position with the right leg flexed is the most appropriate position for administering an enema to a client with severe constipation. This position helps in promoting the flow of the enema solution into the rectum and facilitates the evacuation of stool. Supine position with the head elevated 30 degrees (Choice A) is not ideal for administering an enema as it does not facilitate the flow of the solution. Left lateral position with the right leg flexed (Choice B) is not the best choice for administering an enema. Prone position with the head turned to the side (Choice D) is also not suitable for administering an enema as it does not assist in the proper administration and retention of the solution.

5. The nurse is caring for a client with diabetic ketoacidosis (DKA). Which intervention is most important?

Correct answer: A

Rationale: Administering insulin is the most crucial intervention in managing diabetic ketoacidosis. Insulin helps reduce blood glucose levels and correct metabolic acidosis, which are the primary issues in DKA. Monitoring urine output (Choice B) is important but not as critical as administering insulin. Assessing the client's level of consciousness (Choice C) is essential but does not directly address the underlying cause of DKA. Obtaining an arterial blood gas sample (Choice D) can provide valuable information but is not as urgent as administering insulin to address the immediate metabolic imbalance.

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