Foundations and Adult Health Nursing Test Bank

Correct Answer: C

Rationale: Monitoring cardiac enzymes would be most helpful to Nurse Victor to confirm the underlying cause of cardiogenic shock. Cardiac enzymes are specific markers in the blood that indicate damage to the heart muscle, such as troponin and creatine kinase-MB (CK-MB). When a patient experiences cardiogenic shock, there is usually damage to the heart muscle which leads to the release of these enzymes into the bloodstream. Monitoring cardiac enzymes can help confirm if the cause of cardiogenic shock is related to myocardial infarction or another cardiac issue. This information is crucial for determining the appropriate treatment and management plan for the patient. Monitoring pulmonary artery pressure, mean arterial pressure, and central venous pressure may provide important hemodynamic information but may not directly confirm the underlying cause of cardiogenic shock.

Correct Answer: C

Rationale: Nurse Ace submitting a report to the physician about committing an error in medication demonstrates accountability. Accountability in healthcare refers to the responsibility of individuals to answer for their actions, decisions, and behaviors in the professional setting. By taking ownership of the mistake and informing the physician, Nurse Ace is showing accountability for her actions, ensuring that patient safety remains a priority. Compliance with reporting errors is essential for quality improvement and patient safety in healthcare settings.

Correct Answer: A

Rationale: Troponin is the most specific cardiac biomarker for myocardial injury. Troponin I and Troponin T are proteins released into the bloodstream when there is damage to the heart muscle, making them highly indicative of myocardial infarction. Troponin levels rise within a few hours of cardiac injury, peak within 24-48 hours, and can remain elevated for up to 2 weeks. Troponin is considered the gold standard biomarker for the diagnosis of acute myocardial infarction due to its high specificity and sensitivity for cardiac injury. In contrast, Creatine kinase-MB (CK-MB) and myoglobin are also used in diagnosing myocardial infarction but are less specific than troponin. Brain natriuretic peptide (BNP) is primarily used in heart failure diagnosis and management, and its levels are not specific to myocardial injury.

Correct Answer: A

Rationale: The correct instruction that the nurse should include in patient education about phosphate binder therapy is to "Take phosphate binders with meals." Phosphate binders are medications given to patients with chronic kidney disease to help control high phosphate levels in the blood. Taking phosphate binders with meals allows them to bind to the phosphorus present in the food, reducing its absorption in the body. This helps to lower blood phosphate levels effectively. Instructing the patient to take phosphate binders with meals ensures optimal binding of phosphorus from the diet, which is crucial for managing phosphate levels in patients with chronic kidney disease.

Correct Answer: B

Rationale: The patient's presentation with renal failure, confusion, seizures, asterixis, and a sweet odor to the breath, along with laboratory findings of severe metabolic acidosis, hyperkalemia, and elevated BUN and creatinine levels, is consistent with uremic encephalopathy. Uremic encephalopathy is a neurological complication of acute or chronic renal failure resulting from the buildup of uremic toxins in the blood, leading to various neurological symptoms such as confusion and seizures. The sweet odor to the breath can be attributed to the presence of urea, a waste product that accumulates in renal failure. Other metabolic abnormalities like hyperkalemia and severe metabolic acidosis are also common in renal failure. It is crucial to promptly recognize and manage uremic encephalopathy to prevent further neurological complications.