A nurse is caring for a client who has acute angina. Which of the following actions should the nurse take first?
Administer aspirin.
Measure blood pressure.
Administer nitroglycerin.
Initiate IV access.
The Correct Answer is C
Choice A reason: Administering aspirin is one of the first interventions for a client experiencing acute angina because aspirin has antiplatelet properties that help prevent blood clots, which can reduce the risk of a heart attack.
Choice B reason: Measuring blood pressure is important but not the first action to take. It provides valuable information about the cardiovascular status of the client and can influence further treatment decisions.
Choice C reason: Administering nitroglycerin is a priority action for acute angina as it helps to dilate the coronary arteries and relieve chest pain. However, it is typically administered after aspirin unless contraindicated.
Choice D reason: Initiating IV access is an important step in the management of acute angina, as it allows for the administration of medications and fluids if needed. However, it is not the first action to take during an acute angina episode.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is D
Explanation
Choice A reason: Taking two tablets PO every 15 minutes is not the standard protocol for nitroglycerin administration for chest pain. This method could lead to an overdose and significant hypotension (low blood pressure), which can be dangerous.
Choice B reason: One tablet SL every 15 minutes, up to 5 times, is also not the standard protocol. While sublingual administration is correct, the frequency and the total number of doses are higher than recommended, which could result in adverse effects such as headache, dizziness, or a severe drop in blood pressure.
Choice C reason: One tablet PO every one hour, up to 5 times, is not a recommended method for acute chest pain relief from angina. Oral administration does not provide the rapid onset of action required for acute angina relief.
Choice D reason: One tablet SL every 5 minutes, up to 3 times, is the correct protocol for nitroglycerin administration when experiencing chest pain due to angina. If pain persists after the first dose, the patient can take a second dose after 5 minutes, and if needed, a third dose after another 5 minutes. If chest pain continues after three doses in 15 minutes, emergency medical help should be sought immediately.
Correct Answer is C
Explanation
Choice A reason: Administering aspirin is one of the first interventions for a client experiencing acute angina because aspirin has antiplatelet properties that help prevent blood clots, which can reduce the risk of a heart attack.
Choice B reason: Measuring blood pressure is important but not the first action to take. It provides valuable information about the cardiovascular status of the client and can influence further treatment decisions.
Choice C reason: Administering nitroglycerin is a priority action for acute angina as it helps to dilate the coronary arteries and relieve chest pain. However, it is typically administered after aspirin unless contraindicated.
Choice D reason: Initiating IV access is an important step in the management of acute angina, as it allows for the administration of medications and fluids if needed. However, it is not the first action to take during an acute angina episode.
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