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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is ["B","C","D","E","F"]

Explanation

A. Numbness in extremities: Numbness in extremities is not a common adverse effect of digoxin. The focus of digoxin monitoring is primarily on cardiovascular and gastrointestinal effects.

B. Fatigue: Fatigue is a common adverse effect of digoxin and can indicate toxicity or overdose. Clients taking digoxin should be monitored for increased fatigue or weakness.

C. Shortness of breath: Shortness of breath can occur as an adverse effect of digoxin toxicity, particularly if it leads to pulmonary congestion or heart failure exacerbation.

D. Anorexia: Anorexia, or loss of appetite, can be a gastrointestinal adverse effect of digoxin. Clients may experience nausea, vomiting, or anorexia, which can contribute to weight loss and electrolyte imbalances.

E. Chest pain: Chest pain can be a sign of digoxin toxicity, especially if it is associated with other symptoms such as shortness of breath or palpitations. It is essential to evaluate any chest pain in a client taking digoxin.

F. Confusion: Confusion or changes in mental status can occur with digoxin toxicity, particularly in older adults. Clients should be monitored for signs of confusion, delirium, or other cognitive changes.

Correct Answer is ["5"]

Explanation

To calculate how many milliliters (mL) of metoprolol 1 mg/mL solution should be administered to deliver a 5 mg IV bolus dose, you can use the following formula:

Dose (mL) = Desired dose (mg) / Concentration (mg/mL)

In this case:

Desired dose = 5 mg

Concentration = 1 mg/mL

Dose (mL) = 5 mg / 1 mg/mL = 5 mL

Therefore, the nurse should administer 5 mL of metoprolol 1 mg/mL solution per dose to deliver a 5 mg IV bolus for heart rate control.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client prescribed digoxin. When assessing the client for adverse effects, the nurse should assess for which of the following signs and symptoms? (Select All that Apply.)

Correct Answer is ["B","C","D","E","F"]

Explanation

A nurse is preparing to administer metoprolol 5 mg IV bolus to a client for heart rate control. Available is metoprolol injection 1 mg/mL. How many mL should the nurse administerperdose?

Correct Answer is ["5"]

Explanation

Family members bring a client to the ED with pale cool skin, sudden midsternal chest pain unrelieved with rest, and a history of CAD. How should the nurse best interpret these initial data?

A nurse is caring for a client who is scheduled for a bone marrow aspiration. The client asks the nurse about the sites the provider might use for the procedure. Which of the following locations should the nurse identify as one of the sites used for this procedure?

The mother of a teenage boy with sickle cell anemia asks the nurse why her son has such horrible pain during a sickle cell crisis. Which of the following is the best response by the nurse?

A brain (B-type) natriuretic peptide (BNP) sample has been drawn from an older adult client who has been experiencing fatigue and shortness of breath. This test will allow the care team to investigate the possibility of what diagnosis?

The nurse is collecting data for a client who has been diagnosed with iron-deficiency anemia. What subjective findings does the nurse recognize as symptoms related to this type of anemia?

The nurse caring for a client receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBCs) has begun, the client is having difficulty breathing and complains of severe chest tightness. What is the most appropriate initial action for the nurse to take?

A nurse is educating on the foods a client newly diagnosed with coronary heart disease should eat. How can the nurse best ensure the client will follow the dietary plan of care?