A nurse is providing teaching to a client who has angina pectoris and a new prescription for nitroglycerin sublingual tablets. Which of the following statements by the client indicates an understanding of the teaching?
"I'll dial 911 if I still have pain after taking 4 nitroglycerin tablets over a 20-minute period."
"I'll dial 911 if 1 nitroglycerin tablet does not relieve my pain, and then take up to 2 more tablets 5 minutes apart while waiting."
“I’ll dial 911 when I have pain and then take the nitroglycerin tablets."
"I'll dial 911 if I still have pain after taking 3 nitroglycerin tablets 5 minutes apart."
The Correct Answer is D
A. Taking 4 nitroglycerin tablets is incorrect. The maximum dose is 3 tablets, taken 5 minutes apart. If chest pain persists after the third dose, the client should seek emergency help.
B. Calling 911 after only one dose is incorrect. The correct protocol is to take up to three doses before seeking emergency assistance unless symptoms worsen rapidly.
C. Calling 911 immediately before taking nitroglycerin is incorrect. The client should attempt to relieve the chest pain with nitroglycerin before calling for emergency help.
D. Calling 911 if pain persists after taking 3 nitroglycerin tablets 5 minutes apart is correct. Persistent chest pain despite nitroglycerin use suggests a possible myocardial infarction (MI), requiring immediate medical intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Dizziness is more commonly associated with left-sided heart failure due to decreased cardiac output and reduced cerebral perfusion.
B. Crackles in the lungs occur in left-sided heart failure due to pulmonary congestion. Right-sided heart failure primarily affects systemic circulation rather than the lungs.
C. A dry hacking cough is also a symptom of left-sided heart failure, resulting from fluid backup into the lungs.
D. Hepatomegaly is correct. Right-sided heart failure leads to systemic venous congestion, which can cause liver enlargement (hepatomegaly), ascites, and peripheral edema.
Correct Answer is ["C","D","E"]
Explanation
A. Assessing level of consciousness is a nursing responsibility and cannot be delegated to the UAP.
B. Auscultating breath sounds requires clinical judgment and must be performed by a nurse.
C. Encouraging deep breathing exercises is within the scope of a UAP and can help improve gas exchange.
D. Recording a pulse oximeter reading is a task that can be delegated to a UAP, though interpretation remains the nurse’s responsibility.
E. Keeping the head of the bed elevated helps improve oxygenation and can be done by the UAP.
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