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 D
Explanation
Choice A rationale:
Two loose stools in the past 24 hours could be a symptom of Clostridioides difficile infection, but it’s not necessarily a priority finding. The infection can cause diarrhea, but it’s not life-threatening.
Choice B rationale:
A WBC count of 11,000/mm³ is slightly elevated, indicating a possible infection. However, it’s not necessarily a priority finding as it’s not significantly high.
Choice C rationale:
A heart rate of 104/min is slightly elevated, indicating possible stress or anxiety. However, it’s not necessarily a priority finding as it’s not significantly high.
Choice D rationale:
Creatinine level of 3.1 mg/dL is significantly high, indicating possible kidney damage, which can be a side effect of vancomycin treatment. This should be reported to the provider immediately.
Correct Answer is B
Explanation
Choice A rationale:
Hypernatremia (high sodium levels) is not a common side effect of spironolactone. Spironolactone is a potassium-sparing diuretic and does not typically affect sodium levels.
Choice B rationale:
Hyperkalemia (high potassium levels) is a potential adverse effect of spironolactone. As a potassium-sparing diuretic, spironolactone can cause an increase in serum potassium levels.
Choice C rationale:
Hypophosphatemia (low phosphate levels) is not typically associated with spironolactone use.
Choice D rationale:
Hypocalcemia (low calcium levels) is also not a common side effect of spironolactone.
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