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.

Answer and Explanation

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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Correct Answer is A

Explanation

Choice A reason: Glycosylated hemoglobin, also known as hemoglobin A1C, reflects the average blood glucose levels over the past two to three months. It is a crucial indicator of long-term glycemic control in individuals with diabetes. The American Diabetes Association recommends that the A1C level be checked at least two times a year in patients who are meeting treatment goals and have stable glycemic control. An A1C level below 7% is generally considered good control, and achieving this target can reduce microvascular complications of diabetes.

Choice B reason: Postprandial blood glucose levels indicate the amount of glucose in the blood after a meal. While it's an important measure, it reflects only the immediate response to food intake and does not provide information about long-term glycemic control.

Choice C reason: Fasting blood glucose levels measure the amount of glucose in the blood after an overnight fast. This test is used to detect diabetes or prediabetes but is less effective than the A1C test for monitoring long-term glycemic control.

Choice D reason: The oral glucose tolerance test (OGTT) measures blood glucose levels before and two hours after consuming a glucose-rich drink. This test is primarily used for diagnosing diabetes and gestational diabetes, not for long-term monitoring.

A. Irrigate the affected eye from the inner corner toward the outer corner. B. Sit the client up with their head turned toward the right side. C. Place a strip of pH paper under the upper lid of the affected eye. D. Irrigate the affected eye using sterile water.

Correct Answer is A

Explanation

Choice A reason: Ocular irrigation should be performed from the inner corner (near the nose) toward the outer corner to avoid contaminating the other eye and to ensure that the flushing fluid and any chemical residue flow away from the unaffected eye. This method helps to minimize the risk of spreading the chemical to the other eye and allows for a more effective removal of the chemical from the affected eye.

Choice B reason: While positioning the client upright is correct, having the head turned toward the right side is not specifically recommended. The client should be positioned in a way that facilitates the flow of the irrigation fluid away from the unaffected eye, which typically means tilting the head to the side of the affected eye.

Choice C reason: Placing a strip of pH paper under the upper lid of the affected eye is done to measure the pH of the tear film and determine the acidity or alkalinity of the chemical involved. However, this is not an immediate action during the initial irrigation process. The first priority is to dilute and remove the chemical from the eye as quickly as possible.

Choice D reason: While sterile water can be used for ocular irrigation, it is not the first choice. The preferred solution for ocular irrigation is a saline solution or specific eye irrigating solutions because they are isotonic and less irritating to the eye tissues. Sterile water may cause discomfort due to its hypotonicity, which can lead to cellular swelling.

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A nurse is caring for a client who has acute angina. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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