After administering sublingual nitroglycerin to a client with chest pain, it is most important for the nurse to assess:
Blood pressure.
Blood glucose levels.
Body temperature.
Respiratory rate.
The Correct Answer is A
Choice A reason: This is correct. Blood pressure is the most important vital sign to monitor after giving sublingual nitroglycerin to a client with chest pain. Nitroglycerin is a medication that dilates the blood vessels and lowers the blood pressure. This can relieve the chest pain caused by angina, which is a condition where the heart muscle does not get enough oxygen due to narrowed or blocked arteries. However, if the blood pressure drops too low, the client may experience dizziness, fainting, or shock. Therefore, the nurse should check the blood pressure before and after giving nitroglycerin and report any significant changes to the doctor.
Choice B reason: This is incorrect. Blood glucose levels are not directly affected by sublingual nitroglycerin. However, some clients with chest pain may also have diabetes, which is a risk factor for heart disease. Diabetes is a condition where the body cannot regulate the amount of sugar in the blood. High or low blood sugar levels can cause symptoms such as thirst, hunger, fatigue, blurred vision, or confusion. Therefore, the nurse should check the blood glucose levels of clients with diabetes and follow the doctor's orders for managing their blood sugar.
Choice C reason: This is incorrect. Body temperature is not directly affected by sublingual nitroglycerin. However, some clients with chest pain may also have a fever, which is a sign of infection or inflammation. Fever is a condition where the body's temperature rises above the normal range. Fever can cause symptoms such as sweating, chills, headache, or muscle ache. Therefore, the nurse should check the body temperature of clients with fever and follow the doctor's orders for treating their infection or inflammation.
Choice D reason: This is incorrect. Respiratory rate is not directly affected by sublingual nitroglycerin. However, some clients with chest pain may also have difficulty breathing, which is a sign of heart failure or lung disease. Difficulty breathing is a condition where the client cannot get enough air into or out of the lungs. Difficulty breathing can cause symptoms such as coughing, wheezing, or gasping. Therefore, the nurse should check the respiratory rate of clients with difficulty breathing and follow the doctor's orders for improving their oxygenation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is incorrect. Lisinopril is an angiotensin converting enzyme (ACE) inhibitor that lowers blood pressure and reduces the workload of the heart. It does not have a diuretic effect, meaning it does not increase urination.
Choice B reason: This is correct. Lisinopril can cause orthostatic hypotension, which is a sudden drop in blood pressure when changing positions. This can lead to dizziness, fainting, or falls. To prevent this, the nurse should instruct the client to rise slowly from sitting or lying positions and to avoid sudden movements.
Choice C reason: This is incorrect. Lisinopril can be taken with or without food. Taking it on an empty stomach does not improve its effectiveness or reduce its side effects.
Choice D reason: This is incorrect. Lisinopril does not cause weight gain due to fluid retention. In fact, it can help reduce edema, which is swelling caused by excess fluid in the body.
Correct Answer is C
Explanation
Choice A reason: This is incorrect. Taking an antacid with another antacid is redundant and unnecessary. Antacids are medicines that neutralize the acid in the stomach and relieve symptoms of heartburn, indigestion, and gastric ulcers. Taking too much antacid can cause side effects such as diarrhea, constipation, or electrolyte imbalance¹.
Choice B reason: This is incorrect. Taking an antacid as needed to reduce pain is not a good practice. Antacids are not painkillers and do not address the underlying cause of gastric ulcers. Gastric ulcers are sores in the lining of the stomach that can be caused by infection, inflammation, or erosion. Taking an antacid may temporarily relieve the pain, but it does not heal the ulcer or prevent complications. Antacids should be taken regularly as prescribed by the doctor, along with other medicines that treat the cause of the ulcer.
Choice C reason: This is correct. Taking an antacid after taking a proton pump inhibitor (PPI) is a good practice. PPIs are medicines that reduce the production of acid in the stomach and help heal gastric ulcers. However, PPIs may take several hours to work and may not provide immediate relief of symptoms. Taking an antacid after a PPI can help neutralize any remaining acid in the stomach and provide faster symptom relief. However, the antacid should be taken at least 2 hours after the PPI, as the antacid can interfere with the absorption of the PPI.
Choice D reason: This is incorrect. Reducing fluid intake with an antacid is not a good practice. Fluid intake is important for hydration, digestion, and elimination. Reducing fluid intake can cause dehydration, constipation, or kidney problems. Fluid intake does not affect the effectiveness of antacids, as long as the antacid is taken with a glass of water to help dissolve and flush it down the esophagus and into the stomach.
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