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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Notify the blood bank of the discrepancy:
This choice suggests that there is a discrepancy between the blood type of the unit on hand (type B) and the client's blood type (type AB). However, in reality, there is no discrepancy in this case because individuals with type AB blood are universal recipients and can receive blood from donors of any blood type, including type B. Therefore, there is no need to notify the blood bank of any discrepancy.
B. Administer the blood as ordered:
This choice is the correct action. Type AB individuals are known as universal recipients because they can safely receive blood from donors of any blood type (A, B, AB, or O) without causing a major transfusion reaction. Since the client has type AB blood and the unit of blood on hand is type B, the nurse can administer the blood as ordered without concerns about blood type compatibility.
C. Complete an incident report:
Completing an incident report is typically done when an unexpected event or error occurs during patient care. In this scenario, there is no error or unexpected event related to blood type compatibility, so there is no need to complete an incident report.
D. Contact the provider for further orders:
Contacting the provider for further orders would be necessary if there were a specific reason or concern related to the blood transfusion that requires clarification or additional instructions. However, in this case, there are no issues with blood type compatibility, so contacting the provider is not necessary.
Correct Answer is A
Explanation
A. Work together to see how they can incorporate healthier choices into the foods enjoyed:
This approach emphasizes collaboration between the nurse and the client, focusing on finding ways to incorporate healthier food choices into the client's diet while considering their food preferences and cultural background. By working together, the nurse can help the client identify suitable substitutions, portion control strategies, and meal planning techniques that align with the dietary recommendations for coronary heart disease. This approach promotes active participation, empowers the client to make informed decisions, and increases the likelihood of long-term adherence to the dietary plan.
B. Tell the client if they do not change their diet, they are going to have a myocardial infarction:
This approach uses fear tactics or negative consequences to motivate behavior change, which is generally not recommended in healthcare settings. Fear-based strategies may lead to increased anxiety, stress, or resistance in the client, ultimately hindering motivation and adherence to the dietary plan. Positive reinforcement, education, and collaborative goal-setting are more effective in promoting behavior change and improving adherence to lifestyle modifications.
C. Give the client a list of foods to choose from:
Providing a list of foods can be a helpful tool in guiding food choices and promoting a balanced diet. However, this approach may not address the client's individual preferences, cultural considerations, or practical challenges in implementing dietary changes. Without personalized guidance and support, the client may struggle to navigate food options effectively and may experience difficulties in adhering to the dietary recommendations.
D. It is okay to cheat because of the medications:
Encouraging cheating or deviating from the dietary plan due to medications undermines the importance of dietary modifications in managing coronary heart disease. It is essential to emphasize the significance of following a heart-healthy diet and lifestyle, as medications alone may not be sufficient to manage the condition effectively. Providing education on medication adherence and dietary guidelines, along with ongoing support, helps reinforce the importance of consistent dietary habits in promoting cardiovascular health.
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