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 A

Explanation

A. Exercise ECG stress test: An exercise ECG stress test requires informed consent because it involves physical activity that may place stress on the heart and carries certain risks, such as inducing arrhythmias or other complications.

B. Electrocardiogram: An electrocardiogram (ECG or EKG) is a non-invasive, routine diagnostic test that does not require written informed consent.

C. CT scan without contrast dye: A CT scan without contrast dye is a standard imaging procedure that typically does not require written informed consent, unless there are specific risks or complications involved.

D. Echocardiogram: An echocardiogram is a non-invasive ultrasound test of the heart and does not require written informed consent under normal circumstances.

A. Malaise B. Dyspnea C. Fever D. Anorexia

Correct Answer is B

Explanation

A. Malaise: Malaise is a common symptom of infective endocarditis, indicating generalized discomfort or fatigue. However, it is not an immediate life-threatening condition and does not require urgent intervention.

B. Dyspnea: Dyspnea is the priority because it can indicate heart failure or a pulmonary embolism, both of which are serious complications of infective endocarditis. This requires immediate attention and reporting.

C. Fever: Fever is common in infective endocarditis due to the underlying infection. While important, it is expected and usually managed with antipyretics and antibiotics. It is not as urgent as dyspnea.

D. Anorexia: Anorexia is also a common symptom of infective endocarditis but is not an immediate threat to the client’s health.

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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

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