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2026 Edition.
Which laboratory value will be most important for the nurse to monitor to determine whether a
client with chest pain has acute coronary syndrome (ACS)?
A. Troponin T (cTnT)
B. C-reactive protein (CRP)
C. Low-density lipoprotein (LDL)
D. B-type natriuretic protein (BNP) - Answer A
These are released into circulation within hours after myocardial injury or infarction, and
elevation in troponin levels helps determine that the client is experiencing ACS.
The other three values will also be monitored but are not markers for ACS or acute myocardial
infarction.
C-reactive protein is a marker for inflammation and elevated levels can predict cardiac disease.
Elevated LDL is a risk factor for atherosclerosis and coronary artery disease.
Elevated BNP is diagnostic for heart failure.
To determine whether a client is experiencing acute coronary syndrome (ACS), which
component of the electrocardiogram would the nurse analyze?
A. P wave
B. PR interval
C. QRS complex
D. ST segment - Answer D
Elevation or depression of ST segment is indicative of ACS because of changes in cardiac
electrical activity that occur with ischemia and injury.
P wave changes are not used to diagnose ACS.
Changes in the QRS complex do not occur with ACS.
,A. Attach the cardiac monitor.
B. Auscultate the heart sounds
C. Check the intravenous fluid rate.
D. Assess alertness and orientation. - Answer A
Because fatal dysrhythmias may occur in the first hours after myocardial infarction, cardiac
monitoring is a priority.
The nurse will also do auscultation of the heart, but changes in heart sounds are not expected
with ACS and PCI.
Checking the intravenous line for patency and correct infusion rate is also important, but would
be done after establishing cardiac monitoring.
Neurological status would be assessed, but changes in neurological status are not expected
after PCI, which does not require general anesthesia.
Sublingual nitroglycerin has been prescribed for a client with unstable angina. Which client
response indicates that nitroglycerin is effective?
A. Pain subsides as a result of arteriole and venous dilation.
B. Pulse rate increases because the cardiac output has been stimulated.
C. Sublingual area tingles because sensory nerves are being triggered.
D. Capacity for activity improves as a response to increased collateral circulation. - Answer A
Nitroglycerin causes vasodilation, increasing the flow of blood and oxygen to the myocardium
and reducing anginal pain.
An increased pulse rate does not indicate effectiveness; it is a side effect of nitroglycerin.
The tingling indicates that the medication is fresh; relief of pain is the only indicator of
effectiveness.
Nitroglycerin does not promote the formation of new blood vessels.
Which pain characteristic would the nurse expect to observe when a client is experiencing
anginal pain?
A. Unchanged by rest
, Relief by sublingual nitroglycerin is a classic reaction because it causes vasodilation of peripheral
veins and arteries, thereby decreasing oxygen demand by decreasing preload. To a lesser extent,
sublingual nitroglycerin dilates coronary arteries, which increases oxygen to the myocardium,
thereby decreasing pain.
Immediate rest frequently relieves anginal pain.
Angina usually is precipitated by exertion, emotion, or a heavy meal.
Angina usually is described as tightness, indigestion, or heaviness.
The parent of a child with hemophilia asks the nurse, "If my son hurts himself, is it all right if I
give him two baby aspirins?" Which statement by the nurse is appropriate?
A. "You seem concerned about giving medications to your child."
B. "It's all right to give him baby aspirin when he hurts himself."
C. "Aspirin may cause more bleeding. Give him acetaminophen instead."
D. "He should be given acetaminophen every day. It'll prevent bleeding." - Answer C
Aspirin, which has an anticoagulant effect, is contraindicated because it may harm a child with
bleeding problems; in addition, aspirin is contraindicated for all children because of its
relationship to Reye syndrome.
Stating that the parent seems concerned about giving medications to the child does not answer
the mother's question and may cause the mother to feel defensive.
Acetaminophen cannot prevent bleeding episodes; it is an analgesic.
The mother of a toddler with hemophilia A asks the nurse, "Can I give my child ibuprofen for
fever or pain?" How will the nurse respond?
A. "Ibuprofen is a good choice for fever or pain."
B. "Give your child acetaminophen. Ibuprofen may cause bleeding."
C. "No. I'll explain why your child isn't allowed pain medications."
D. "You seem concerned about giving medications to your child." - Answer B
The parent is asking a specific question that should be answered by the nurse.
Ibuprofen is contraindicated because it interferes with platelet function and may cause more