A nurse is reinforcing discharge teaching about sublingual nitroglycerin with a client who has angina. Which of the following statements indicates an understanding of the instructions?
"I am going to take the medication with food.”
"I understand that the medication can slow my heart rate.”
"I should feel the effects of the medication within 5 minutes.”
"I will take the medication every 10 minutes until the pain goes away.”
The Correct Answer is C
Choice A rationale:
The statement about taking the medication with food is incorrect. Nitroglycerin sublingual tablets should not be taken with food. They work much faster when absorbed through the lining of the mouth.
Choice B rationale:
The statement that the medication can slow the heart rate is incorrect. Nitroglycerin does not slow the heart rate. In fact, it can cause a reflex tachycardia, where the heart rate increases.
Choice C rationale:
The statement that the effects of the medication should be felt within 5 minutes is correct. This indicates an understanding of the instructions.
Choice D rationale:
Taking the medication every 10 minutes until the pain goes away is incorrect. Nitroglycerin sublingual tablets usually give relief in 1 to 5 minutes. However, if the pain is not relieved, a second tablet can be taken 5 minutes after the first tablet. If the pain continues for another 5 minutes, a third tablet may be used. Taking the medication every 10 minutes could lead to an overdose.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
A respiratory rate of 10/min is lower than the normal range (12-20 breaths per minute for adults), indicating respiratory depression, which is a serious side effect of morphine and should be reported immediately.
Choice B rationale:
Facial flushing is a common side effect of morphine due to histamine release but it’s not life-threatening.
Choice C rationale:
Constipation is a common side effect of morphine and can be managed with laxatives and diet.
Choice D rationale:
Blood pressure 88/56 mm Hg is lower than the normal range (90/60mmHg to 120/80mmHg), indicating hypotension, which can be a side effect of morphine but it’s not as immediately life-threatening as respiratory depression.
Correct Answer is B
Explanation
Choice A rationale:
Fever is not a common side effect of acetaminophen. In fact, acetaminophen is often used to reduce fever.
Choice B rationale:
Jaundice, which is a yellowing of the skin or eyes, can be a sign of liver damage, a rare but serious side effect of acetaminophen.
Choice C rationale:
Diarrhea is not a common side effect of acetaminophen.
Choice D rationale:
Tinnitus, or ringing in the ears, is not a common side effect of acetaminophen.
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