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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Cheyne-Stokes respirations, characterized by a pattern of irregular breathing with periods of apnea, can be a sign of brain stem compression due to increased intracranial pressure. However, it is not typically the first sign of deteriorating neurological status.
Choice B reason: Pupillary dilation, especially if it is unilateral, can indicate pressure on the cranial nerves due to increased intracranial pressure. It is a concerning sign but may not be the first to appear as neurological function deteriorates.
Choice C reason: An altered level of consciousness is often the first sign of deteriorating neurological status in a patient with increased intracranial pressure. Changes in consciousness can range from slight disorientation or confusion to complete unresponsiveness.
Choice D reason: Decorticate posturing, which involves abnormal flexion of the arms with extension of the legs, indicates significant brain injury and is a later sign of increased intracranial pressure, not typically the first sign.
Correct Answer is C
Explanation
Choice A: Rinse your mouth with hydrogen peroxide
Rinsing the mouth with hydrogen peroxide is not recommended for clients with mucositis. Hydrogen peroxide can be too harsh and may cause further irritation to the already sensitive mucosal lining. It is generally advised to use mild rinses such as saline or baking soda solutions.
Choice B: Brush your teeth for 60 seconds twice daily
While brushing is important, it should be done gently with a soft-bristled toothbrush, and the timing should be based on patient tolerance rather than a strict 60-second rule.
Choice C: Floss your teeth gently following each meal
Gentle flossing helps remove food particles and bacteria, reducing the risk of infection. However, if bleeding occurs, the patient should stop and consult a healthcare provider.
Choice D: Wear your dentures only during meals
Wearing dentures only during meals might be advisable for some clients with mucositis, as wearing them all day could irritate the inflamed oral tissues. However, it’s important for the dentures to fit properly and for the client to have periods of rest without the dentures to allow the oral tissues to heal.
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