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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Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A reason : A tongue blade should not be placed in the mouth during a seizure as it can cause injury or obstruct the airway.

Choice B reason: An NG tube, or nasogastric tube, is not typically required in the immediate management of seizures and should not be inserted during an active seizure due to the risk of injury.

Choice C reason: An oral airway may be used to maintain a patent airway during a postictal state if the client is unable to maintain their own airway.

Choice D reason: Wrist restraints are not routinely recommended for clients with seizure disorders as they can cause injury during a seizure. Safe environment and proper positioning are preferred to prevent injury.

A. Check the client's blood pressure every 8 hours. B. Monitor for hypokalemia as a manifestation of acute rejection. C. Assess urine output hourly. D. Administer opioids orally.

Correct Answer is C

Explanation

Choice A reason: Checking the client's blood pressure every 8 hours is important, but it is not as critical as monitoring urine output in the immediate postoperative period. Blood pressure should be monitored regularly, but changes in urine output can provide more immediate information about the new kidney's function.

Choice B reason: Monitoring for hypokalemia is important, as it can be a sign of acute rejection; however, hyperkalemia is more commonly associated with acute rejection due to the kidney's inability to excrete potassium. Therefore, while electrolyte monitoring is crucial, the focus is typically on hyperkalemia rather than hypokalemia.

Choice C reason: Assessing urine output hourly is essential for a client who has undergone a kidney transplant. Urine output is a direct indicator of the new kidney's function, and any significant decrease could indicate a complication such as acute rejection or obstruction.

Choice D reason: Administering opioids orally for pain management is part of postoperative care, but it is not the priority over monitoring urine output and kidney function.

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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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