After administering nitroglycerin spray to a client experiencing angina, which action should the nurse implement next?
Compress the client's nares.
Observe for facial flushing.
Advise the client to rest.
Elevate the client's feet.
The Correct Answer is C
A. Compress the client's nares: Compressing the nares is a technique used for nasal medication administration or controlling nosebleeds, not for sublingual or oral spray forms of nitroglycerin. This action is unrelated to nitroglycerin use for angina.
B. Observe for facial flushing: Facial flushing is a common side effect of nitroglycerin due to vasodilation. While it should be noted during monitoring, it is not the immediate next action after administration when addressing angina symptoms.
C. Advise the client to rest: Resting after nitroglycerin administration reduces myocardial oxygen demand, helping to relieve anginal pain more effectively. It also helps prevent hypotension and dizziness, which are common side effects of the medication.
D. Elevate the client's feet: Elevating the feet is typically done if hypotension occurs. It is not a standard next step immediately after giving nitroglycerin unless the client shows symptoms like syncope or significant blood pressure drops.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Determine what time the dose is taken: Dextroamphetamine-amphetamine is a stimulant that can interfere with sleep if taken too late in the day. The timing of the dose is crucial because early morning dosing minimizes insomnia, making this the most important initial assessment.
B. Ask about the client's bedtime routine: While bedtime routines can influence sleep quality, stimulant medication timing has a much stronger direct effect on insomnia, making this a secondary consideration after reviewing dose timing.
C. Inquire about perceived anxiety: Anxiety can contribute to sleep difficulties, but in clients taking stimulants, medication effects are a more likely cause. Addressing medication-related factors takes priority over psychological causes in this case.
D. Determine daily caffeine intake: Caffeine may worsen insomnia, but stimulant medications are generally a stronger factor in causing sleep disturbances. Assessing caffeine use is important but not the first priority compared to reviewing medication timing.
Correct Answer is A
Explanation
A. Positive guaiac of stool: A positive guaiac test indicates the presence of blood in the stool, suggesting gastrointestinal bleeding. Given the client’s history of frequent ibuprofen use, which can cause gastric ulcers and GI bleeding, this is a critical finding that must be reported immediately to the healthcare provider.
B. Hemoglobin 13 g/dL (130 g/L): Although slightly below the normal reference range for males, a hemoglobin of 13 g/dL is not critically low. It suggests mild anemia but is not an urgent finding compared to evidence of active gastrointestinal bleeding.
C. Hematocrit 42% (0.42 volume fraction): A hematocrit of 42% falls within the normal reference range for a male client. Therefore, this finding is stable and does not require immediate reporting in the context of the client's current symptoms.
D. Gastric pH 2: A gastric pH of 2 is within the normal range for stomach acid levels (1.5 to 3.5). The current gastric pH suggests that their acid production is within expected limits and is not the immediate concern. This value does not indicate any acute problem by itself and would not require immediate notification of the healthcare provider.
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