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 min, the client states that his chest pain is now a severity of 2. Which of the following actions should the nurse take?

Initiate a peripheral IV.

Administer another nitroglycerin tablet.

Call the Rapid Response Team.

Obtain an ECG.

Answer and Explanation

The Correct Answer is B

A. Initiate a peripheral IV:

Initiating a peripheral intravenous (IV) line may be necessary for clients with unstable angina to facilitate the administration of medications and fluids, especially if there is a need for further interventions or if the client's condition deteriorates. However, in this case, the client's chest pain has improved after receiving nitroglycerin, and there is no immediate indication for IV access based on the information provided.

B. Administer another nitroglycerin tablet:

Nitroglycerin is a vasodilator commonly used to relieve chest pain (angina) by dilating blood vessels and improving blood flow to the heart. The initial response of the client's chest pain severity decreasing from 6 to 2 after one sublingual nitroglycerin tablet indicates a positive response to the medication. However, it's important to assess the client's response further before administering additional doses of nitroglycerin, especially considering the potential for hypotension or other adverse effects.

C. Call the Rapid Response Team:

The Rapid Response Team (RRT) is typically called in situations where there is a concern for a critical event or deterioration of a client's condition that requires immediate intervention. In this scenario, the client's chest pain has improved after nitroglycerin administration, and there are no indications of an acute critical event at this time. Therefore, calling the RRT is not warranted based on the client's current status.

D. Obtain an ECG:

An ECG can be helpful to assess for potential ischemia or other cardiac abnormalities. However, it's not the most urgent action when the client is responding positively to nitroglycerin. It can be done while monitoring the client's response to the second dose.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Monitor weight daily: Daily weight monitoring is a crucial aspect of assessing fluid balance in clients with heart failure. Sudden weight gain can indicate fluid retention, which may be a sign of worsening heart failure. The nurse should instruct the client to weigh themselves at the same time each day, preferably in the morning after emptying the bladder and before eating breakfast, and to report any significant weight changes to their healthcare provider.

B. Assess radial pulses daily: While assessing radial pulses is important for monitoring cardiovascular status, it is not specifically focused on assessing fluid balance in heart failure. Radial pulse assessment is more related to evaluating cardiac output and peripheral perfusion.

C. Monitor bowel movements: Monitoring bowel movements is not directly related to assessing fluid balance in heart failure. Although changes in bowel habits can sometimes be associated with fluid and electrolyte imbalances, it is not the primary method for assessing fluid balance in this context.

D. Monitor blood pressure daily: While monitoring blood pressure is important for managing hypertension and evaluating cardiovascular status, it is not specifically focused on assessing fluid balance in heart failure. Blood pressure monitoring is more related to assessing hemodynamic stability and response to medications.

A. Folic acid deficiency anemia B. Pernicious anemia C. Iron-deficiency anemia D. Sickle cell anemia

Correct Answer is C

Explanation

A. Folic acid deficiency anemia:

Folic acid deficiency anemia is characterized by a lack of folate (vitamin B9), which is essential for red blood cell production. Symptoms can include weakness and fatigue, similar to iron-deficiency anemia. However, folic acid deficiency anemia typically does not cause heavy menstrual periods. Laboratory findings may show a low level of folate in the blood, but the hemoglobin level of 8 g/dL and hematocrit level of 28 g/dL alone do not specifically indicate folic acid deficiency anemia without considering other factors like mean corpuscular volume (MCV) and red blood cell indices.

B. Pernicious anemia:

Pernicious anemia is caused by a lack of intrinsic factor, a substance needed for the absorption of vitamin B12. It can lead to symptoms such as weakness and fatigue. However, heavy menstrual periods are not a characteristic feature of pernicious anemia. Laboratory findings may show a low hemoglobin and hematocrit level, but again, other factors such as MCV and vitamin B12 levels would be needed to confirm this type of anemia.

C. Iron-deficiency anemia:

Iron-deficiency anemia occurs due to insufficient iron stores in the body, leading to decreased hemoglobin and hematocrit levels. This type of anemia is commonly associated with symptoms like weakness, fatigue, and heavy menstrual periods in women due to blood loss. The client's hemoglobin level of 8 g/dL and hematocrit level of 28 g/dL are consistent with iron-deficiency anemia, making this the most likely choice based on the information provided.

D. Sickle cell anemia:

Sickle cell anemia is a genetic disorder characterized by abnormal hemoglobin that causes red blood cells to become sickle-shaped and less flexible. It typically presents with symptoms such as anemia, pain crises, and organ damage. However, the client's symptoms of weakness, fatigue, and heavy menstrual periods are not specific to sickle cell anemia. Additionally, sickle cell anemia would have different laboratory findings, including a different pattern on peripheral blood smear and hemoglobin electrophoresis.

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Naxlex Comprehensive Predictor Exams

The nurse is providing discharge education to a client diagnosed with heart failure. What should the nurse teach this client to do to assess fluid balance in the home setting?

Correct Answer is A

Explanation

A nurse is caring for a young female adult client who reports weakness, fatigue, and heavy menstrual periods. The client has a hemoglobin level of 8 g/dL and a hematocrit level of 28 g/dL. The nurse suspects which of the following types of anemia?

Correct Answer is C

Explanation

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