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. Obtain a blood sample. While obtaining a blood sample to check cardiac enzyme levels is important for diagnosing myocardial injury, it is not the priority over oxygen therapy, given the client’s shortness of breath and cyanosis.

B. Insert the IV catheter. IV access is important for administering fluids and medications, but it is not the first priority in this scenario where the client is experiencing respiratory distress.

C. Initiate oxygen therapy. The client shows signs of hypoxia (shortness of breath and cyanosis), and oxygen is crucial for stabilizing oxygen levels and preventing further deterioration of cardiac and respiratory function.

D. Attach the leads for a 12-lead ECG. Attaching the leads for an ECG is essential to evaluate the client's cardiac status, but it is not the most urgent action in the presence of cyanosis and respiratory distress.

A. Eggs B. Milk C. Beans D. Liver

Correct Answer is C

Explanation

A. Eggs: Eggs, particularly the yolks, are high in cholesterol and should be limited in a low-cholesterol diet.

B. Milk: Full-fat milk is high in saturated fat and cholesterol. If the client consumes milk, it should be low-fat or non-fat varieties.

C. Beans: Beans are high in fiber and low in fat and cholesterol. They are an excellent choice for a low-cholesterol diet.

D. Liver: Liver is high in cholesterol and should be avoided by clients following a low-cholesterol diet.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a client about following a low-cholesterol diet after coronary artery bypass grafting. Which of the following food choices reflects the client's understanding of these dietary instructions?

Correct Answer is C

Explanation

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