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."

Answer and Explanation

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.

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Correct Answer is A

Explanation

A) Ask the client to rate her pain on a scale from 0 to 10:
Assessing the client's pain intensity is the first essential step in managing postoperative pain. Understanding the severity of pain will guide the nurse in determining the appropriate intervention and whether immediate pain relief measures or further assessment are needed.

B) Reposition the client and offer her a back rub:
Repositioning and providing comfort measures like a back rub can help alleviate discomfort, but assessing the pain level first is crucial to prioritize interventions effectively.

C) Determine the time the client last received pain medication:
Knowing the timing of the last pain medication dose is important but assessing current pain intensity takes precedence to determine if the client needs immediate pain relief.

D) Measure the client's vital signs, including temperature:
While vital signs are important for overall assessment, addressing pain management and comfort should be the initial focus after the client reports incisional pain postoperatively.

A. BP of 132/82 mm Hg B. Heart rate of 66/min C. Digoxin level of 1.2 ng/mL D. Potassium level of 3.0 mEq/L

Correct Answer is D

Explanation

A) BP of 132/82 mm Hg: This blood pressure reading is within the normal range for most adults and does not typically indicate a need to withhold digoxin or report to the provider. Digoxin's primary concerns are related to heart rate and electrolyte levels rather than blood pressure.

B) Heart rate of 66/min: A heart rate of 66 beats per minute is within the normal range for adults. While digoxin is used to manage heart rate, particularly in atrial fibrillation, this heart rate does not indicate an immediate need to report to the provider or withhold the medication.

C) Digoxin level of 1.2 ng/mL: This digoxin level falls within the therapeutic range, which is typically 0.8 to 2.0 ng/mL for most patients. Therefore, this finding does not indicate digoxin toxicity or a need to report to the provider.

D) Potassium level of 3.0 mEq/L: A potassium level of 3.0 mEq/L is below the normal range (3.5-5.0 mEq/L) and indicates hypokalemia. Hypokalemia can increase the risk of digoxin toxicity, as low potassium levels can enhance digoxin's effects on the heart. Therefore, this finding is significant and should be reported to the provider to prevent potential adverse effects and complications.

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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?

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Correct Answer is D

Explanation

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