The nurse has an order to administer an I.M. injection using the Z-track technique. When carrying out this order, what should the nurse do?
When giving an I.M. injection using the Z-track technique, the nurse pulls the skin laterally away from the injection site, inserts the needle at a 90-degree angle, waits 10 seconds after injecting the medication, and then simultaneously withdraws the needle and releases the skin.
A client is scheduled for surgery at 8 a.m. While completing the preoperative checklist, the nurse sees that the surgical consent form hasn't been signed. It's time to administer the preoperative analgesic. Which nursing action takes the highest priority in this situation?
Notifying the surgeon takes priority because informed consent must be obtained before the client receives drugs that can alter cognition. Giving the preoperative analgesic at the scheduled time would alter the client's ability to give informed consent. Obtaining consent for surgery isn't within the scope of nursing practice, although the nurse may confirm or witness consent. Canceling surgery also isn't within the scope of nursing practice.
The nurse teaches a client with newly diagnosed hypothyroidism about the need for thyroid hormone replacement therapy to restore normal thyroid function. Which thyroid preparation is the agent of choice for thyroid hormone replacement therapy?
a) Thyroid USP desiccated (Thyroid USP Enseals)
b) Methimazole (Tapazole)
c) Liothyronine (Cytomel)
d) Levothyroxine (Synthroid)
Levothyroxine is the agent of choice for thyroid hormone replacement therapy because its standard hormone content gives it predictable results. Methimazole is an antithyroid medication used to treat hyperthyroidism. Thyroid USP desiccated and liothyronine are no longer used for thyroid hormone replacement therapy because they may cause fluctuating plasma drug levels, increasing the risk of adverse effects
A client with acute asthma showing inspiratory and expiratory wheezes and a decreased forced expiratory volume should be treated immediately with which class of medication?
The nurse is caring for a client with type 1 diabetes who exhibits confusion, light-headedness, and aberrant behavior. The client is still conscious. The nurse should first administer:
A client with type 1 diabetes must learn how to self-administer insulin. The physician has prescribed 10 units of U-100 regular insulin and 35 units of U-100 isophane insulin suspension (NPH) to be taken before breakfast. When teaching the client how to select and rotate insulin injection sites, the nurse should provide which instruction?
The nurse should instruct the client to rotate injection sites within the same anatomic region. Rotating sites among different regions may cause excessive day-to-day variations in the blood glucose level; also, insulin absorption differs from one region to the next. Insulin should be injected only into healthy tissue lacking large blood vessels, nerves, or scar tissue or other deviations. Injecting insulin into areas of hypertrophy may delay absorption. The client shouldn't inject insulin into areas of lipodystrophy (such as hypertrophy or atrophy). To prevent lipodystrophy, the client should rotate injection sites systematically and use one anatomical region for a week. Exercise speeds drug absorption, so the client shouldn't inject insulin into sites above muscles that will be exercised heavily.
A client with a diagnosis of diabetes insipidus is being treated with desmopressin acetate (DDAVP). The client asks why he has been ordered this medication. The nurse plans her response based on the understanding that DDAVP:
Diabetes insipidus results from a deficiency of circulating antidiuretic hormone (vasopressin). Desmopressin acetate, a synthetic vasopressin, is the medication of choice for treating diabetes insipidus. Glucocorticoids are hormones secreted by the adrenal gland, which isn't involved with diabetes insipidus. Insulin and oral antidiabetic agents are used to treat diabetes mellitus, a disorder of glucose metabolism.
A client is admitted to the emergency department with an acute asthma attack. The physician prescribes ephedrine sulfate, 25 mg subcutaneously (subQ). How soon should the ephedrine take effect?
Which nursing intervention should be taken for a client who vomits 1 hour after taking his morning glyburide (DiaBeta)?
Monitor blood glucose closely and look for signs of hypoglycemia
Explanation: When a client who has taken an oral antidiabetic agent vomits, the nurse should monitor glucose and assess him frequently for signs of hypoglycemia. Most of the medication has probably been absorbed. Therefore, repeating the dose would further lower glucose levels later in the day. Giving insulin will also lower glucose levels, causing hypoglycemia. The client wouldn't have hyperglycemia if the glyburide had been absorbed.
An 86-year-old female client who has been on long-term steroid therapy now has drug-induced Cushing syndrome. She's resid-ing in an extended-care facility because of her multiple chronic health problems. Which condition is closely related to chronic use of steroids?
Thin, easily damaged skin
Explanation: Clients taking steroids on a long-term basis lose subcutaneous fat under the skin and are especially vulnerable to skin breakdown and bruising. Such clients should take great care when performing tasks that may injure the skin and should anticipate delayed healing when injuries occur. Clients taking long-term steroids are likely to have hyperglycemia. Prolonged steroid use can cause depression. Clients who experience weight loss should be monitored for weight gain and edema.
Which instruction concerning the administration of levothyroxine (Synthroid) should the nurse teach a client?
"Take the drug on an empty stomach."
Explanation: The nurse should instruct the client to take levothyroxine on an empty stomach (to promote absorption) in the morning (to help prevent insomnia and to mimic normal hormone release).
Following a pulmonary embolism, a client is placed on I.V. heparin. The client asks the nurse about the purpose of the heparin. Which statement by the nurse is the correct explanation of the purpose of heparin therapy?
slow the development of more clots
When administering spironolactone (Aldactone) to a client who has had a unilateral adrenalectomy, the nurse should instruct the client about which possible adverse effect of the drug?
Explanation: Spironolactone can cause menstrual irregularities and decreased libido. Men may also experience gynecomastia and impotence. Breast tenderness, decreased facial hair, and hair loss aren't associated with spironolactone.
Which of the following is an adverse reaction to glipizide (Glucotrol)?
Explanation: Glipizide may cause adverse skin reactions, such as rash, pruritus, and photosensitivity. It doesn't cause heartburn, excess hair growth, or hypotension.
Every morning a client with type 1 diabetes receives 15 units of Humulin 70/30. What does this type of insulin contain?
70% NPH insulin and 30% regular insulin
Explanation: Humulin 70/30 insulin is a combination of 70% NPH insulin and 30% regular insulin.
A client is receiving Novolin insulin every morning. When would the nurse expect the client to possibly develop hypoglycemia?
A nurse administers glucagon to her diabetic client and then monitors the client for adverse drug reactions and interactions. Which type of drug interacts adversely with glucagon?
Explanation: As a normal body protein, glucagon only interacts adversely with oral anticoagulants, increasing the anticoagulant effects. It doesn't interact adversely with anabolic steroids, beta-adrenergic blockers, or thiazide diuretics.
A client with type 1 diabetes is admitted to an acute care facility with diabetic ketoacidosis. To correct this acute diabetic emergency, which measure should the health care team take first?
Initiate fluid replacement therapy.
Explanation: The health care team first initiates fluid replacement therapy to prevent or treat circulatory collapse caused by severe dehydration. Although diabetic ketoacidosis results from insulin deficiency, the client must have an adequate fluid volume before insulin can be administered; otherwise, the drug won't circulate throughout the body effectively. Therefore, insulin administration follows fluid replacement therapy. Determining and correcting the cause of diabetic ketoacidosis are important steps, but the client's condition must be stabilized first to prevent life-threatening complications.
A client with chronic obstructive pulmonary disease (COPD) takes anhydrous theophylline, 200 mg by mouth every 8 hours. During a routine clinic visit, the client asks the nurse how the drug works. What is the mechanism of action of anhydrous theophylline in treating a nonreversible obstructive airway disease such as COPD?
It makes the central respiratory center more sensitive to carbon dioxide and stimulates the respiratory drive.
Explanation: Anhydrous theophylline and other methylxanthine agents make the central respiratory center more sensitive to CO2 and stimulate the respiratory drive. Inhibition of phosphodiesterase is the drug's mechanism of action in treating asthma and other reversible obstructive airway diseases — not COPD. Methylxanthine agents inhibit rather than stimulate adenosine receptors. Although these agents reduce diaphragmatic fatigue in clients with chronic bronchitis or emphysema, they don't alter diaphragm movement to increase chest expansion and enhance gas exchange.
A nurse is preparing to administer regular insulin 4 units subcutaneously to a client with type 1 diabetes mellitus. Which equipment does the nurse need to perform the injection? Select all that apply:
• Medication administration record
• 27-gauge, 1/2" needle
Explanation: To administer medication, the nurse needs the medication administration record to verify the correct client, medication, dose, time, and route. A subcutaneous injection, such as insulin, is administered with a 25-gauge to 27-gauge, 5/8" to 1/2" needle. The nursing assessment sheet isn't necessary for administering insulin. A 22-gauge needle is too large for a subcutaneous injection. A 1" needle will deliver the medication into muscle rather than subcutaneous tissue.
A client with hyperparathyroidism develops renal calculi. The nurse should expect to see which electrolyte levels?
Increased calcium levels
Explanation: Renal calculi usually consist of calcium and phosphorus. In hyperparathyroidism, serum calcium levels are high, leading to renal calculi formation. Potassium and magnesium don't form renal calculi, and levels of these minerals aren't high in clients with hyperparathyroidism.
The nurse knows that many drugs can be administered by more than one route. Which administration route provides the most rapid response in a client?
Explanation: A drug dissolved in the mouth enters the client's bloodstream more quickly, thereby avoiding the barriers of food and the destructive effects of stomach acid. With oral, I.M., or subQ administration, the response to the drug is slower.
A nurse reviews the laboratory data of a 60-year-old client. The data reveals increased blood and urine levels of triiodothyronine (T3) and thyroxine (T4). The nurse knows these values are associated with which condition?
Explanation: Hyperthyroidism causes high levels of T3 and T4. A definitive diagnosis of Addison's disease must reflect low levels of adrenocortical hormones. Cushing syndrome manifests as excessive amounts of adrenocortical hormones. Lower pituitary hormone secretion levels are consistent with hypopituitarism.
A client who's admitted with new-onset diabetes mellitus is prescribed an 1,800-calorie diabetic diet. His insulin orders include regular insulin coverage using a sliding scale, and long-acting insulin every morning just before breakfast. Why was the sliding scale insulin coverage prescribed?
Directs the nurse to administer regular insulin doses according to finger-stick glucose levels without notifying the physician
Explanation: The sliding scale directs the nurse to administer doses of regular insulin to the client according to finger-stick glucose levels without notifying the physician. For instances in which the client is able and the physician allows, the client may administer his own regular insulin according to a sliding scale. A sliding scale directs regular — not long-acting — insulin administration after finger-stick glucose levels are obtained.
The nurse is caring for a 62-year-old client with type 2 diabetes. The client takes an oral antidiabetic to control blood glucose levels. The physician prescribed ramipril (Altace) to help treat this client's elevated blood pressure. The nurse should be alert for which drug interaction?
Explanation: Insulin and oral antidiabetics given in conjunction with ramipril can increase the risk of hypoglycemia, especially at the start of ramipril therapy. When given with potassium-sparing diuretics, ramipril increases the risk of hyperkalemia because ramipril reduces potassium loss. Excessive hypotension may occur when ramipril is given with diuretics. Sodium retention may occur if ramipril is combined with the herb licorice. This effect may increase blood pressure, interfering with the therapeutic effects of ramipril.
A client requests his medication at 9 p.m. instead of 10 p.m. so he can go to sleep earlier. Which type of nursing intervention is required?
Explanation: Nursing interventions are classified as independent, interdependent, or dependent. Altering the drug schedule to coincide with the client's daily routine represents an independent intervention, whereas consulting with the physician and pharmacist to change a client's medication because of adverse reactions represents an interdependent intervention. Administering an already-prescribed drug on time is a dependent intervention. An intradependent nursing intervention doesn't exist.
A client with hypothyroidism is prescribed levothyroxine (Synthroid) 0.05 mg by mouth daily before breakfast. As the nurse gives the client the medication, the client states, "What dose am I getting? I've been taking 0.15 mg every day for years." Which action by the nurse is most appropriate?
Verifying the dose with the physician's order on the client's medical record
Explanation: The nurse must ensure that the correct client is receiving the correct dose of the correct drug, and at the correct time. Therefore, the nurse must verify the dose with the physician's order located in the client's medical record. Option 2 doesn't address the client's concern or prevent a potential medication administration error. The nurse shouldn't recheck the dose against what's written on the medication administration record because a transcription error might have occurred, resulting in the wrong dose.
The nurse is developing a teaching plan for a client who has just been diagnosed with breast cancer. The nurse should include information about which medication?
Explanation: Tamoxifen is an estrogen-blocker used to treat premenopausal and postmenopausal breast cancer and to prevent breast cancer in certain women who are at high risk. Acetaminophen is a nonopioid analgesic antipyretic. Dopamine is a vasoconstrictor used to treat hypotension. Progesterone is a hormone used to treat amenorrhea or dysfunctional uterine bleeding.
The physician prescribes 20 units of U-100 regular insulin for a client. The only syringe available is a 1-ml tuberculin syringe. How many milliliters of insulin should the nurse administer?
Explanation: The nurse should calculate the does as follows:
100 units/1 ml = 20 units/X
X = 0.2 ml
The nurse is teaching a client how to administer subcutaneous (subQ) insulin injections. Which injection site would be appropriate for the client to use?
Anterior aspect of the thigh
Explanation: SubQ injection sites, which are relatively distant from bones and major blood vessels, include the lateral aspects of the upper arm, the anterior aspects of the thigh, and the abdomen. The deltoid, rectus femoris, and vastus lateralis are I.M. injection sites
A client is prescribed digoxin (Lanoxin) 0.125 mg by mouth now. The pharmacy dispenses digoxin 0.25 mg. The nurse promptly administers the medication and then realizes she has administered the wrong dose. How should the nurse proceed?
Obtain vital signs and notify the physician and nursing supervisor immediately of the the error.
Explanation: The nurse should obtain vital signs and notify the physician and nursing supervisor of the error. An incident report should then be completed to document the occurrence. The nurse administering the drug is legally responsible for ensuring that she calculates and administers the correct dose. She shouldn't immediately inform the pharmacist. The incident will be shared with the pharmacy supervisor after completion of the incident report.
What is the first action that a nurse should take after accidentally failing to administer an ordered medication?
Notify the prescriber, nursing supervisor, and pharmacist.
Explanation: When a nurse has accidentally omitted an ordered medication, she should first notify the prescriber, nursing supervisor, and pharmacist. She should then document the omission and the reason in the client's chart and, depending on facility policy, write an incident report. The nurse shouldn't give an extra dose at the next scheduled time because adverse reactions or toxicity could occur.
A client who sustained a head injury in a motor vehicle accident is prescribed phenytoin (Dilantin) liquid to prevent seizures. The client is unable to take anything by mouth and has a feeding tube in place for enteral feedings. Which intervention by the nurse is most appropriate when administering phenytoin to this client?
Administering the phenytoin 2 hours before or 2 hours after beginning the tube feedings
Explanation: Enteral nutrition therapy may reduce orally administered phenytoin concentrations. Therefore, the nurse should give phenytoin 2 hours before starting enteral feeding or 2 hours after stopping enteral feeding. It isn't necessary to have the dose administered I.V. Bleeding complications can occur if the client is receiving warfarin (Coumadin) in conjunction with phenytoin, but there's nothing in this scenario to indicate that the client is receiving warfarin.
Which type of solution, when administered I.V., would cause a shift of fluid from the interstitial space to the intravascular space?
Explanation: A hypertonic solution causes fluids to be absorbed into the intravascular space until equal pressure is established on both sides of the blood vessel. A hypotonic solution causes fluids to move from the intravascular space into the interstitial space. An isotonic solution has no effect on the cell. A sodium chloride solution can be isotonic, hypertonic, or hypotonic, depending on the concentration of sodium.
A client is to receive a glycerin suppository. Which nursing action is appropriate when administering a suppository?
Applying a lubricant to the suppository
Explanation: A suppository should be lubricated before insertion to ease insertion and reduce discomfort. The nurse should assist the client in a left-side lying position (not right- side lying) to ease insertion. Because suppositories melt at body temperature, they usually require refrigeration until administration. Instructing the client to bear down would cause the anal sphincter to contract, making insertion difficult.
To give a Z-track injection, the nurse measures the correct medication dose and then draws a small amount of air into the syringe. What is the rationale for this action?
Adding air prevents the drug from flowing back into the needle track.
Explanation: The added air flushes the drug from the syringe, ensuring that the drug goes into the muscle tissue, and preventing it from flowing back into the needle track, which could cause skin staining. Adding air doesn't decrease pain (which results from the drug's chemical composition), and it has no bearing on whether the drug enters a blood vessel. Adding air isn't necessary to ensure that the client receives the entire dose.
A client develops hepatic encephalopathy 1 week after portal caval shunt surgery. Her physician prescribes neomycin (Mycifradin), 4 g by mouth daily in four divided doses. Her husband asks how neomycin decreases his wife's serum ammonia concentration. How should the nurse respond?
"It decreases the number of ammonia-producing bacteria in the GI tract."
Explanation: Neomycin lowers the blood ammonia level by reducing the number of ammonia-producing bacteria in the GI tract. The drug also exerts its antibacterial activity directly on the ribosomes of susceptible organisms, among them E. coli, by inhibiting protein synthesis via direct action on ribosomal subunits. When these bacteria are present, they convert urea to ammonia. Neomycin is bactericidal in high concentrations and bacteriostatic in low concentrations. Thus, it doesn't trap or bind with ammonia in the GI tract.
The nurse is caring for a patient who has had an acute MI. The patient is receiving lidocaine IV. What is the most relevant factor to administration of this medication?
Presence of premature ventricular contractions (PVCs) on cardiac monitor
Explanation: Lidocaine (xylocaine) may be used in the patient with acute MI. Patients with acute MI who did not receive thrombolytics and had more than 10 PVCs per hour and those who did receive thrombolytics and had more than 25 PVCS per hour were found to be at the greatest risk for sudden cardiac death. SaO2, blood pressure, and ICP are important factors but aren't as significant as PVCs in this situation.
When providing care to the client who has undergone a dilatation and curettage (D&C;) after a spontaneous abortion, the nurse administers hydroxyzine (Vistaril) as ordered. Which of the following is an expected outcome?
Absence of nausea.
Explanation: Hydroxyzine (Vistaril) has a tranquilizing effect and also decreases nausea and vomiting. It does not decrease fluid retention, reduce pain, decrease uterine cramping, or promote uterine contractility. One of the adverse effects of the medication is sleepiness. Ibuprofen may decrease pain from uterine cramping. Oxytocin may be used to increase uterine contractility.
A patient would be considered overweight but not obese if he or she had a body mass index (BMI) of which of the following?
Explanation: Overweight is defined as a BMI of 25 to 29.9 kilograms per square meter.
A client has been receiving chemotherapy to treat cancer. Which data collection finding suggests that the client has developed stomatitis (inflammation of the mouth)?
Red, open sores on the oral mucosa
Explanation: The tissue-destructive effects of cancer chemotherapy typically cause stomatitis, resulting in ulcers on the oral mucosa that appear as red, open sores. White, cottage cheese-like patches on the tongue suggest a candidal infection, another common adverse effect of chemotherapy. Yellow tooth discoloration may result from antibiotic therapy, not cancer chemotherapy. Rust-colored sputum suggests a respiratory disorder, such as pneumonia.
A new graduate nurse lists which of the following as uses for opioid antagonists? (Check all that apply.)
• postoperative acute respiratory depression
• opioid adverse effects (reversal)
• suspected acute opioid overdosage
Explanation: Opioid antagonists are used for the treatment of postoperative acute respiratory depression, opioid adverse effects (reversal), and suspected acute opioid overdosage.
The nurse is assessing the patient receiving chlorpromazine hydrochloride (Thorazine) as part of his therapy for migraines. What assessment indicates a therapeutic effect of this therapy?
The patient does not have nausea.
Explanation: The patient receives Thorazine as an antiemetic and to relieve the pain of migraine headaches. The patient does not receive this medication for seizures or to create amnesia in pain control.
A client with asthma has been prescribed beclomethasone (Beclovent) via metered-dose inhaler. To determine if the client has been rinsing the mouth after each use of the inhaler, the nurse should inspect the client's mouth for:
Explanation: Beclomethasone is an inhaled steroid used for the maintenance treatment of asthma. The steroid can precipitate overgrowth of fungus, such as oral Candida albicans. Rinsing the mouth well after each use decreases the incidence of oral fungal infections. Beclomethasone does not cause gingival hyperplasia, ulceration, or caries.
You are caring for a male patient who is taking an MAOI. The patient complains of seasonal rhinitis and the intern for his service orders phenylephrine nasal spray. What should you do before administering this drug?
Question the order with the prescriber
Explanation: Phenylephrine, combined with MAOIs, can cause severe hypertension, headache, and hyperpyrexia. This combination should be avoided. You would not verify the patency of the nares, have another nurse double check the order, or give the drug as ordered.
A student nurse is administering medications at a long-term care facility. Which of the following liquid medications is for topical administration?
Explanation: Eye drops are instillations—liquids for topical use. Liquid medication when used to flush out or irrigate a wound is also topical administration. Mouthwash, syrups, and tinctures are not used for topical administration.
A 70-year-old man who enjoys good health began taking low-dose aspirin several months ago based on recommendations that he read in a magazine article. During the man's most recent visit to his care provider, routine blood work was ordered and the results indicated an unprecedented rise in the man's serum creatinine and blood urea nitrogen (BUN) levels. How should a nurse best interpret these findings?
The man may be experiencing nephrotoxic effects of aspirin
Explanation: Damage to the kidneys is called nephrotoxicity. Decreased urinary output, elevated blood urea nitrogen, increased serum creatinine, altered acid-base balance, and electrolyte imbalances can all occur with kidney damage.
The nurse is reviewing a client's medication list. This client just recently delivered her first child but has a few chronic problems. The nurse recognizes which of the following drugs are not recommended to be used during lactation? Select all that apply.
Explanation: Numerous medications are contraindicated or not recommended during lactation because they enter the breast milk and have an adverse effect on the infant. They include tetracycline, loratadine, and lithium.
Referring to a route of medication administration that uses the gastrointestinal tract, such as swallowing a pill.
adm. dosage by route and time prescribed
administered by means other than through the alimentary tract (as by intramuscular or intravenous injection)
A client has been prescribed a diet that limits purine-rich foods. Which food would the nurse teach her to avoid eating?
Anchovies, sardines, kidneys, sweetbreads, and lentils
Explanation: Anchovies, sardines, kidneys, sweetbreads, and lentils are high in purines. Bananas and dried fruits are high in potassium. Milk, ice cream, and yogurt are rich in calcium. Wine, cheese, preserved fruits, meats, and vegetables contain tyramine
After a transsphenoidal adenohypophysectomy, a client is likely to undergo hormone replacement therapy. A transsphenoidal adenohypophysectomy is performed to treat which type of cancer?
Explanation: Pituitary carcinoma most commonly arises in the anterior pituitary (adenohypophysis) and must be removed by way of a transsphenoidal approach, using a bivalve speculum and rongeur. Esophageal carcinoma is treated with surgery, which usually is palliative and involves esophagogastrectomy with jejunostomy. Laryngeal carcinoma may necessitate a laryngectomy. To treat colorectal carcinoma, the surgeon removes the tumor and any adjacent tissues and lymph nodes that contain cancer cells.
Which effect can thoracic kyphoscoliosis have on lung function?
Restricts lung expansion
Explanation: Thoracic kyphoscoliosis causes lung compression, restricts lung expansion, and results in more rapid and shallow respiration. It doesn't cause obstruction or reduce alveolar compression during expiration. It also doesn't improve lung expansion because of the compression.
Which steps should the nurse follow to insert a straight urinary catheter?
Prepare the client and the equipment, create a sterile field, put on gloves, clean the urinary meatus, and insert the catheter until urine flows.
Explanation: Option 3 describes all the vital steps for inserting a straight catheter. Option 1 is incorrect because the nurse must prepare the client and equipment before creating a sterile field. Option 2 is incorrect because the nurse put on gloves before creating a sterile field and performing the other tasks. Option 4 describes the procedure for inserting an indwelling catheter, rather than a straight catheter.
A client is admitted with severe nausea, vomiting, and diarrhea and is hypotensive. She's noted to have severe oliguria with ele-vated blood urea nitrogen (BUN) and creatinine levels. The physician will most likely write an order for which treatment?
Start I.V. fluid of normal saline solution bolus followed by a maintenance dose
Explanation: The client is experiencing prerenal failure secondary to hypovolemia. I.V. fluids should be given to rehydrate the client; urine output should increase, and the BUN and creatinine levels will normalize. The client wouldn't be able to tolerate oral fluids because of the nausea, vomiting, and diarrhea. The client isn't fluid overloaded, and her urine output won't increase with furosemide. The client won't need dialysis because the oliguria and increased BUN and creatinine levels are due to dehydration.
A client with a history of severe angina is being seen in the emergency department for chest pain. In terms of diagnostic laboratory testing, it's most important for the nurse to advocate ordering a:
Explanation: Troponin is a myocardial cell protein that is elevated in the serum when myocardial damage has occurred during a myocardial infarction (MI). It's the best serum indicator of MI and is more indicative of cardiac damage than creatine kinase. Hb values and liver panel components aren't as useful in the diagnosis of MI as a troponin level.
For a client with suspected increased intracranial pressure (ICP), the most appropriate respiratory goal is to:
promote carbon dioxide elimination.
Explanation: The goal of treatment is to prevent acidemia by eliminating carbon dioxide. An acid environment in the brain causes cerebral vessels to dilate and therefore increases ICP. Preventing respiratory alkalosis and lowering arterial pH may bring about acidosis, an undesirable condition in this case. It isn't necessary to maintain a PaO2 as high as 80 mm Hg; 60 mm Hg will adequately oxygenate most clients.