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. Intermittent claudication with pallor is typically associated with peripheral artery disease (PAD) rather than myocardial infarction.
B. Jugular vein distention and dependent edema are signs of right-sided heart failure, which may develop after an MI but are not classic acute MI symptoms.
C. Mid-epigastric pain and heartburn can sometimes be confused with MI symptoms, but heartburn alone is not diagnostic of an MI.
D. Diaphoresis and cool clammy skin are correct. These symptoms occur due to sympathetic nervous system activation in response to cardiac ischemia, leading to vasoconstriction, sweating, and signs of impending shock.
Correct Answer is A
Explanation
A. Crossing the legs can actually increase the risk of venous stasis and clot formation, which can lead to a pulmonary embolism. The client needs further teaching to avoid this habit.
B. Smoking increases the risk of blood clot formation, so quitting smoking is an appropriate preventive measure.
C. Staying hydrated helps maintain good blood flow and reduces the risk of clot formation.
D. Regular exercise and weight management help prevent venous stasis and clot formation, lowering the risk of pulmonary embolism.
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