A nurse is teaching a client who has angina about sublingual nitroglycerin. Which of the following instructions should the nurse include?

Lie down when taking the mediation.

Chew the medication thoroughly.

Store the medication in the refrigerator.

Check the expiration date on the medication every 6 months.

Answer and Explanation

The Correct Answer is A

A. Lie down when taking the medication: Sublingual nitroglycerin causes vasodilation, which can lower blood pressure and potentially cause dizziness or fainting. The client should lie down or sit in a comfortable position to minimize the risk of falls or injury.

B. Chew the medication thoroughly: Sublingual nitroglycerin should be placed under the tongue and allowed to dissolve completely, not chewed. Chewing may affect the absorption and effectiveness of the medication.

C. Store the medication in the refrigerator: Sublingual nitroglycerin should be stored at room temperature, away from moisture and heat, not in the refrigerator. Cold storage could reduce the medication's effectiveness.

D. Check the expiration date on the medication every 6 months: While it is important to check the expiration date, every 6 months is not sufficient. The client should check the expiration date more frequently (e.g., every 3 months) and replace the medication if expired to ensure it is effective when needed.

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Correct Answer is A

Explanation

A. "If you have a cat, wear gloves when cleaning the litter box.": Cat litter can contain Toxoplasma or Bartonella, which can increase the risk of infection and sepsis in immunocompromised clients. Wearing gloves reduces exposure to potential pathogens.
B. "Floss your teeth after every meal.": Flossing after every meal may be too frequent and could cause irritation or gum injury, which increases the risk of infection. Good oral hygiene is important, but over-flossing should be avoided, especially for clients at risk of sepsis.
C. "Store your toothbrush in a glass filled with distilled water.": Storing a toothbrush in distilled water does not provide additional protection against infection. The toothbrush should simply be kept clean and dry to avoid bacterial growth.
D. "Do not consume cold drinks that have been left out for more than 1 hour.": This advice is generally good for food safety but is not specifically related to sepsis risk. The main focus should be on preventing infections that could lead to sepsis, rather than on drink temperature.

A. Apply mitten restraints to prevent the client from disconnecting their tube feeding. B. Apply soft heel protectors bilaterally while client is in bed. C. Apply a vest restraint daily at bedtime to prevent nighttime wandering. D. Apply an abduction pillow between the client's knees while they are in bed to prevent hip dislocation.

Correct Answer is C

Explanation

A. Apply mitten restraints to prevent the client from disconnecting their tube feeding: Mitten restraints are often used to prevent clients from pulling out tubes or disrupting medical devices. The nurse can apply these restraints as long as they follow the prescribed protocol.

B. Apply soft heel protectors bilaterally while client is in bed: Soft heel protectors are commonly used to prevent pressure ulcers or skin breakdown in immobile clients. This is a standard, non-controversial intervention and does not require verification.

C. Applying a vest restraint daily at bedtime to prevent nighttime wandering is considered a physical restraint used for convenience or punishment, which is a violation of client rights and safety. Restraints should only be used as a last resort when all less restrictive alternatives have failed and for the shortest duration possible.

D. Apply an abduction pillow between the client's knees while they are in bed to prevent hip dislocation: The use of an abduction pillow is common after hip replacement surgery or for patients at risk of hip dislocation. This is an appropriate intervention.

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A nurse is teaching a client who has angina about sublingual nitroglycerin. Which of the following instructions should the nurse include?

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