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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Measure the client's ankle circumference. This is a correct action, as the ankle circumference is necessary to ensure that the stockings fit snugly and provide the proper amount of compression to prevent venous stasis.
B. Measure from the client's heel to the gluteal fold. This measurement would be appropriate for thigh-high stockings, not knee-high stockings.
C. Measure from the client's heel to the popliteal space. For knee-high stockings, measuring from the heel to the popliteal space (behind the knee) ensures the stockings fit properly without cutting off circulation or causing discomfort.
D. Measure the length of the client's feet. Foot length is not necessary for knee-high stockings, as their primary function is to apply compression from the ankle to the knee.
Correct Answer is A
Explanation
A. Troponin T: Troponin T remains elevated for 10 to 14 days after a myocardial infarction. This protein is highly specific for cardiac muscle injury and is used to confirm myocardial infarction.
B. Creatinine phosphokinase: Creatinine phosphokinase (CPK) typically returns to normal levels within 3 days after a myocardial infarction, so it would no longer be elevated at this point.
C. Myoglobin: Myoglobin rises early after a myocardial infarction but is not specific to heart muscle and returns to normal within 24 hours, so it would not be elevated at this time.
D. Creatinine kinase-MB: Creatinine kinase-MB (CK-MB) usually returns to normal levels within 2 to 3 days after a myocardial infarction, so it is unlikely to still be elevated 6 days later.
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