A nurse receives report that a client has been pacing the hallway continuously for almost twenty-four hours and talking excessively.
Which action is the priority?

Maintain trust and avoid behaviors that may increase agitation.

Order the client to go to their room & alert security.

Tell the client to sit down or risk isolation and loss of privileges.

Sedate the client after collecting a lithium level.

Answer and Explanation

The Correct Answer is A

Maintain trust and avoid behaviors that may increase agitation. This is because the client is likely experiencing a manic episode, which is characterized by increased activity, rapid speech, and decreased need for sleep. The nurse should use a calm and supportive approach, provide a safe and structured environment, and avoid confrontation or criticism.

Choice B is wrong because ordering the client to go to their room and alerting security would escalate the situation and violate the client’s rights.

Choice C is wrong because telling the client to sit down or risk isolation and loss of privileges would be threatening and punitive, which could increase the client’s agitation and anger.

Choice D is wrong because sedating the client after collecting a lithium level would be premature and inappropriate without a physician’s order and without assessing the client’s vital signs, mental status, and medication history. Lithium is a mood stabilizer that can cause toxicity if the level is too high.

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Correct Answer is C

Explanation

Determining whether chest pain has been relieved. This is because nitroglycerin is a medication that is used to treat chest pain caused by cardiac origin or acute pulmonary edema. The main action of nitroglycerin is to relax and dilate the blood vessels, which reduces the workload of the heart and improves blood flow to the heart muscle.

Therefore, the most important nursing action after administering nitroglycerin sublingually is to assess if the chest pain has subsided or not.

Choice A is wrong because monitoring the client’s respiratory rate and effort is not the most important action after giving nitroglycerin. Although nitroglycerin can cause hypotension and bradycardia, which may affect the respiratory status, these are side effects that can be managed and are not life-threatening as chest pain.

Choice B is wrong because warning the client to lie still to prevent a headache is not a priority after giving nitroglycerin. Nitroglycerin can cause headache as a side effect, but this can be treated with analgesics and does not require the client to lie still. Moreover, lying still may increase the risk of venous thromboembolism in a client with peripheral vascular disease.

Choice D is wrong because verifying that the sublingual tablet produced a tingling sensation is not essential after giving nitroglycerin.

Although some sublingual tablets may produce a tingling sensation, this is not a reliable indicator of the drug’s effectiveness

A. 5 mL. B. 15 mL. C. 25 mL. D. 30 mL.

Correct Answer is D

Explanation

30 mL. This is because one ounce is equal to 29.57353 milliliters, so one ounce of an elixir medication is approximately 30 milliliters.

The nurse should instruct the client to take 30 milliliters of the medication during discharge teaching.

Choice A is wrong because 5 milliliters is much less than one ounce. Choice B is wrong because 15 milliliters is half of one ounce.

Choice C is wrong because 25 milliliters is slightly less than one ounce.

The nurse should use a conversion factor or a calculator to convert ounces to milliliters accurately.

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A nurse receives report that a client has been pacing the hallway continuously for almost twenty-four hours and talking excessively. Which action is the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which nursing action is most important after administering nitroglycerin sublingually?

Correct Answer is C

Explanation

A health care provider prescribes one ounce of an elixir medication for a client. How many milliliters (mL) of medication should the nurse instruct the client to take during discharge teaching?

Correct Answer is D

Explanation

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A nurse receives report that a client has been pacing the hallway continuously for almost twenty-four hours and talking excessively.
Which action is the priority?