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"

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Hydrocodone. This is an opioid analgesic appropriate for moderate to severe pain, such as a pain rating of 7/10. It is commonly used for acute pain management in cases like fractures and provides effective relief when non-opioids are insufficient.
B. Acetaminophen. While useful for mild to moderate pain, acetaminophen alone is likely inadequate for severe pain like that associated with a fracture rated 7/10.
C. Fentanyl. Fentanyl is a potent opioid used for severe or chronic pain, often in controlled settings such as surgery or cancer care. For an acute fracture, hydrocodone is typically preferred unless pain is extreme or uncontrolled.
D. Aspirin. Aspirin is primarily used for mild pain or anti-inflammatory purposes and is not appropriate as a first-line agent for severe pain. Additionally, it may increase the risk of bleeding, which is a consideration in trauma cases.

A. Perform the Credés maneuver B. Maintain the irrigation solution rate. C. Warm the irrigation solution. D. Replace the indwelling urinary catheter

Correct Answer is B

Explanation

A. Perform the Credé’s maneuver. This technique, involving manual pressure on the bladder, is used to promote urination in clients with bladder retention. It is not appropriate for a client with a catheter and continuous bladder irrigation in place.
B. Maintain the irrigation solution rate. Pink-tinged urine is an expected finding 4 hours after a TURP as minor bleeding can occur. There is no need to adjust the irrigation rate unless clots form or the urine becomes bright red or obstructed.
C. Warm the irrigation solution. Warming the solution is not a standard intervention and does not directly manage postoperative bleeding or pink urine. Room temperature solution is typically used unless otherwise specified by the provider.
D. Replace the indwelling urinary catheter. There is no indication the catheter is malfunctioning or obstructed. Pink urine alone does not warrant replacement, and unnecessary catheter changes can increase infection risk.

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A nurse is teaching a client about self-administration of sublingual nitroglycerin. Which of the following statements should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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