A nurse at a provider's office receives a telephone call from a client who reports nausea and has unrelieved chest pain after taking a nitroglycerin tablet 5 min ago. Which of the following is an appropriate response by the nurse?

Tell the client to take another nitroglycerin tablet in 15 min.

Advise the client to take an antacid.

Advise the client to come into the office.

Instruct the client to call 911.

Answer and Explanation

The Correct Answer is D

A. Tell the client to take another nitroglycerin tablet in 15 minutes. Nitroglycerin can be taken every 5 minutes, up to three doses, for chest pain. Waiting 15 minutes to take another dose is too long and can delay necessary treatment.

B. Advise the client to take an antacid. Antacids are not appropriate for managing chest pain that may be related to angina or a myocardial infarction. This response may delay critical treatment.

C. Advise the client to come into the office. This would delay care in a potential emergency situation. If the client is experiencing unrelieved chest pain after taking nitroglycerin, immediate emergency care is necessary.

D. Instruct the client to call 911. Chest pain unrelieved by nitroglycerin is a sign of a possible myocardial infarction, which is a medical emergency. The client should call 911 immediately to receive urgent care.

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Correct Answer is C

Explanation

A. Call the client's home for someone to pick up the client. This is not appropriate in an emergency situation. The client reporting chest pain needs immediate attention, and arranging for pick-up is not a priority.

B. Call for a code blue. Code blue is reserved for clients in cardiac or respiratory arrest. The nurse needs to assess the severity of the chest pain first before calling a code.

C. Ask another nurse to assess the client who reports chest pain. The priority is to ensure that the client reporting chest pain is assessed immediately. Delegating this task to another nurse allows prompt care for the client with potential cardiac issues while ensuring that the first client continues to receive care.

D. Alert the RN to assess the client reporting chest pain: While notifying the RN is important, it may delay the initial assessment and intervention needed for the client with chest pain. Delegating to another available nurse is a more immediate action.

A. "Was your son born with this cardiac defect?" B. "Has your son had a sore throat recently?" C. "Has your child had any injuries recently?" D. "Are you aware that your son will have to be in isolation?"

Correct Answer is B

Explanation

A. "Was your son born with this cardiac defect?" Rheumatic fever is an acquired condition, often following a streptococcal throat infection, not a congenital (born with) cardiac defect.

B. "Has your son had a sore throat recently?" Rheumatic fever commonly follows a streptococcal throat infection, so asking about a recent sore throat is relevant and important for diagnosis.

C. "Has your child had any injuries recently?" Recent injuries are unrelated to the development of rheumatic fever and are not a pertinent question.

D. "Are you aware that your son will have to be in isolation?" Isolation is not typically required for rheumatic fever, as it is not contagious in this stage.

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A nurse at a provider's office receives a telephone call from a client who reports nausea and has unrelieved chest pain after taking a nitroglycerin tablet 5 min ago. Which of the following is an appropriate response by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An emergency department nurse is collecting information from a client who has stable vital signs when their other client begins to report chest pain. Which of the following should be the nurse's priority?

Correct Answer is C

Explanation

A nurse is assisting with the admission of a 9-year-old child who has acute rheumatic fever. When obtaining the client's history, it is appropriate for the nurse to ask the parent which of the following questions?

Correct Answer is B

Explanation

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