A nurse is reinforcing teaching with a client who has angina pectoris about starting therapy with nitroglycerin sublingual tablets. Which of the following statements by the client indicates an understanding of the teaching?
"I will take the first tablet when the pain becomes severe."
"I will take no more than four tablets in 10 min."
"I will chew the tablet before swallowing."
"I will dial 911 if one tablet does not relieve my pain."
The Correct Answer is D
A) "I will take the first tablet when the pain becomes severe.": This statement is incorrect because nitroglycerin should be taken at the onset of chest pain, not when it becomes severe. Early administration can help prevent the pain from worsening and reduce the risk of a heart attack. Waiting until the pain is severe may delay relief and increase the risk of serious complications.
B) "I will take no more than four tablets in 10 min.": This is incorrect as the standard protocol for nitroglycerin sublingual tablets typically involves taking one tablet every 5 minutes, up to three doses in 15 minutes, if needed. Taking four tablets in 10 minutes exceeds the recommended dosage and could lead to severe hypotension, dizziness, and fainting. It’s crucial to follow the prescribed limits to avoid these adverse effects.
C) "I will chew the tablet before swallowing.": This is incorrect because nitroglycerin sublingual tablets are designed to dissolve under the tongue for rapid absorption into the bloodstream. Chewing or swallowing the tablet would decrease its effectiveness and delay pain relief. The sublingual route allows the medication to bypass the digestive system and work quickly to relieve chest pain.
D) "I will dial 911 if one tablet does not relieve my pain.": This is the correct response. If chest pain is not relieved within 5 minutes after taking the first nitroglycerin tablet, it may indicate a more serious condition such as a heart attack. The client should call 911 to seek immediate medical assistance. Prompt action is critical in managing potential cardiac events and improving outcomes for the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["7.5"]
Explanation
We can calculate the volume of potassium chloride solution to administer using the following steps:
Identify the prescribed dose: The nurse needs to administer 20 mEq of potassium chloride.
Identify the concentration of available solution: The potassium chloride liquid is available in a concentration of 40 mEq/15 mL. This means there are 40 milliequivalents (mEq) of potassium chloride in every 15 milliliters (mL) of the solution.
Set up a proportion to find the volume needed:
Desired dose (mEq) : Volume to administer (mL) = Concentration (mEq/mL)
Plug in the values:
20 mEq : Volume to administer (mL) = 40 mEq/15 mL
Solve for the volume:
To isolate the volume (mL), multiply both sides of the proportion by the volume unit (mL) and divide by the dose (mEq).
Volume to administer (mL) = (20 mEq) x (mL) / (40 mEq/15 mL)
We can simplify the calculation before dividing:
Volume to administer (mL) = (20 mEq x 15 mL) / 40 mEq
Volume to administer (mL) = 300 mL / 40 mEq
Volume to administer (mL) = 7.5 mL (round to one decimal place)
Therefore, the nurse should administer 7.5 mL of the potassium chloride solution.
Correct Answer is C
Explanation
A) "Heparin enhances the effects of the warfarin.": This statement is incorrect. Heparin and warfarin work through different mechanisms. Heparin acts quickly by inhibiting clot formation through antithrombin, while warfarin acts slower by inhibiting vitamin K-dependent clotting factors. They do not directly enhance each other's effects.
B) "Both heparin and warfarin work together to dissolve the clots.": This is inaccurate. Neither heparin nor warfarin dissolve existing clots; they prevent new clots from forming and existing clots from growing. The body's natural processes will eventually dissolve the clot.
C) "Heparin will be continued until the warfarin reaches a therapeutic level!": This is correct. Heparin is used initially because it acts quickly. Warfarin takes several days to reach therapeutic levels. Overlapping the two ensures continuous anticoagulation until warfarin is effective.
D) "I will ask the charge nurse to call your provider and get an explanation.": While involving the provider for further explanation can be helpful, it does not directly answer the client’s question. Providing accurate information about the overlapping use of heparin and warfarin is more appropriate in this context.
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