A nurse on a telemetry unit is caring for a client who has unstable angina and is reporting chest pain with a severity of 6 on a 0 to 10 scale.The nurse administers 1 sublingual nitroglycerin tablet.
After 5 minutes, the client states that his chest pain is now a severity of 2. Which of the following actions should the nurse take?
Obtain an ECG.
Call the Rapid Response Team.
Administer another nitroglycerin tablet.
Initiate a peripheral IV.
The Correct Answer is C
Choice C rationale
Administering another nitroglycerin tablet is appropriate if the client's chest pain has not been fully relieved after the initial dose. Nitroglycerin helps to dilate blood vessels, improving blood flow to the heart and relieving angina. A second dose can be given if the pain persists, following the protocol for managing chest pain.
Choice A rationale
Obtaining an ECG is important for diagnosing and monitoring cardiac conditions; however, in this immediate context, further pain relief takes precedence. After ensuring pain relief, an ECG can be performed to assess the client's cardiac status.
Choice B rationale
Calling the Rapid Response Team is unnecessary if the client’s chest pain severity has already decreased. The priority should be to continue managing the chest pain with additional nitroglycerin if needed and monitoring the client's response.
Choice D rationale
Initiating a peripheral IV might be required for administering medications or fluids, but it is not the immediate action needed in this scenario. The priority is to provide additional pain relief with nitroglycerin.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Stress and anxiety can contribute to gastrointestinal issues, but they are not the most likely cause of a duodenal ulcer.
Choice B rationale
Nonsteroidal anti-inflammatory drugs (NSAIDs) can cause gastrointestinal irritation and ulcers, but Helicobacter pylori infection is a more common cause.
Choice C rationale
Excessive alcohol consumption can irritate the stomach lining and contribute to ulcer formation, but Helicobacter pylori infection is more likely to be the primary cause.
Choice D rationale
Helicobacter pylori infection is the most common cause of duodenal ulcers. The bacteria damage the protective lining of the stomach and duodenum, leading to ulcer formation. .
Correct Answer is B
Explanation
Choice A rationale
A complete blood count (CBC) can provide information about the client's overall health and presence of infection, but it does not specifically address the potential underlying cause related to the urinary system.
Choice B rationale
Urinalysis with culture is the most relevant diagnostic test for evaluating the underlying cause of fever, chills, and severe left costovertebral pain. These symptoms suggest a possible urinary tract infection or pyelonephritis, which can be confirmed with urinalysis and culture.
Choice C rationale
A chest X-ray would not be the priority in this scenario as the symptoms suggest a urinary tract issue rather than a respiratory problem. A chest X-ray is more useful for assessing lung conditions.
Choice D rationale
A CT scan of the abdomen and pelvis can be helpful in evaluating the extent of a urinary tract infection or identifying other causes of abdominal pain, but it is typically not the first-line diagnostic test. Urinalysis with culture is more specific for identifying urinary infections. .
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