A client with unstable angina pectoris receives a prescription for nitroglycerin 0.4 mg sublingually PRN chest pain every 5 minutes x3. The prescription directions include leaving the medication at the bedside for self-administration. Which assessment finding should the practical nurse (PN) obtain first?
Number of tablets taken in past 24 hours.
Level of orientation and compliance.
Heart rate and blood pressure.
Hourly urinary output and daily weight.
The Correct Answer is B
A. While knowing the number of tablets taken is important for managing chest pain, it is secondary to ensuring that the client can safely administer the medication.
B. Assessing the client's level of orientation and compliance is crucial because the client needs to understand how and when to use the nitroglycerin properly. Misunderstanding or non-compliance could lead to ineffective treatment or potential harm.
C. Checking heart rate and blood pressure is important for assessing the effects of nitroglycerin, but before leaving the medication for self-administration, it is vital to ensure that the client understands how to use the medication.
D. Monitoring hourly urinary output and daily weight is not relevant to the immediate concern of ensuring safe and effective nitroglycerin self-administration.
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Related Questions
Correct Answer is D
Explanation
A. Telling the client to focus on the positive aspects of life might seem dismissive of the client's current emotional state and concerns.
B. Providing information about support groups is helpful but should follow an initial supportive and empathetic response.
C. Allowing the client privacy may be necessary later, but initially, it is important to offer support and presence.
D. Sitting quietly with the client and answering any questions demonstrates empathy, support, and availability, helping the client process the new diagnosis and feel less isolated.
Correct Answer is A, F, E
Explanation
A. Take the child's pulse
Assessing the pulse is crucial to determine if the child has a heartbeat and to evaluate the effectiveness of CPR. This helps to determine the current cardiovascular status of the child and the urgency of further resuscitation efforts.
F. Determine if the child's airway is clear
Ensuring a clear airway is a priority in any emergency situation. A blocked airway can prevent effective ventilation and oxygenation, which is critical for a child who has experienced a near-drowning incident.
D. Start a peripheral IV line
Starting a peripheral IV line is important for administering fluids and medications that may be necessary for resuscitation and stabilization. It allows for rapid access to the child's circulatory system for necessary interventions.
E. Look for any open wounds
Checking for open wounds is necessary to identify any immediate sources of bleeding or potential infections that need to be addressed. It is part of a thorough initial assessment to ensure comprehensive care for the child.
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