A nurse is teaching a client about self-administration of sublingual nitroglycerin. Which of the following statements should the nurse include?
"You should take a dose every night at bedtime."
“You should take this medication with food."
"You may repeat a dose after five minutes."
“You may crush this medication if needed"
The Correct Answer is C
A. "You should take a dose every night at bedtime." Sublingual nitroglycerin is not taken on a routine schedule like bedtime. It is used as needed at the onset of chest pain or before activities that might trigger angina, not as a preventive nightly dose.
B. “You should take this medication with food." Sublingual nitroglycerin is placed under the tongue and absorbed directly into the bloodstream, bypassing the gastrointestinal system. It does not require administration with food.
C. "You may repeat a dose after five minutes." If chest pain persists after the first dose, the client may take one tablet every 5 minutes, up to a total of three doses within 15 minutes. If the pain continues after the third dose, emergency services should be contacted.
D. “You may crush this medication if needed." Sublingual tablets should never be crushed or swallowed, as this would prevent proper absorption through the oral mucosa and reduce the medication’s effectiveness in relieving acute chest pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Palms of the hands. In clients with dark skin, assessing for cyanosis is best done in areas where skin is lighter and blood vessels are more visible, such as the palms, soles, lips, mucous membranes, and conjunctiva. These sites provide clearer visual cues of decreased oxygenation.
B. Area of trauma. This area may show signs of bruising or inflammation, but it is not ideal for assessing cyanosis. Local changes in color may be due to injury, not systemic oxygenation.
C. Sacrum. The sacrum is typically assessed for pressure injuries, not for cyanosis. Its location and frequent pressure make it a less reliable site for detecting systemic color changes.
D. Shoulders. The shoulders are not reliable sites for detecting cyanosis, especially in individuals with darker skin, as color changes may be less apparent in more heavily pigmented or sun-exposed areas.
Correct Answer is C
Explanation
A. "You will feel your baby moving within the next month." Fetal movement, or quickening, is typically felt between 16 and 20 weeks of gestation. At 9 weeks, it is too early for the client to detect fetal movement.
B. "Hormone shifts often cause vulvar itching." Vulvar itching is not a common or expected symptom of early pregnancy and may indicate an infection, such as a yeast infection, rather than a normal hormonal change.
C. "You should consume at least 3 liters of fluid each day." Adequate hydration is essential during pregnancy to support increased blood volume, amniotic fluid, and metabolic processes. A daily intake of about 3 liters of fluid helps prevent dehydration and constipation.
D. “Headaches are expected throughout pregnancy." While headaches can occur, especially in the first trimester due to hormonal changes, persistent or severe headaches may indicate complications like preeclampsia and should not be considered a normal, ongoing expectation.
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