nurse is caring for a client who is newly-admitted and has angina. The client asks the nurse, "Why am I taking nitroglycerin?" Which of the lowing responses should the nurse make?
"Nitroglycerin dilates cardiac blood vessels to deliver more oxygen to the heart."
"Nitroglycerin relieves nausea and prevents vomiting, which could lead to aspiration."
"Nitroglycerin acts as a bronchodilator to open small airways and decrease shortness of breath."
"Nitroglycerin decreases chest pain by dissolving blood clots that are occluding the arteries."
The Correct Answer is A
A. "Nitroglycerin dilates cardiac blood vessels to deliver more oxygen to the heart." Nitroglycerin works by dilating the coronary arteries, increasing blood flow and oxygen delivery to the heart muscle, thereby reducing angina.
B. "Nitroglycerin relieves nausea and prevents vomiting, which could lead to aspiration." Nitroglycerin does not have an antiemetic function or impact nausea and vomiting.
C. "Nitroglycerin acts as a bronchodilator to open small airways and decrease shortness of breath." Nitroglycerin is not a bronchodilator. It does not act on the airways but instead works on blood vessels.
D. "Nitroglycerin decreases chest pain by dissolving blood clots that are occluding the arteries." Nitroglycerin does not dissolve blood clots. Thrombolytic agents are used for clot dissolution, not nitroglycerin.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Measure the client's ankle circumference. This is a correct action, as the ankle circumference is necessary to ensure that the stockings fit snugly and provide the proper amount of compression to prevent venous stasis.
B. Measure from the client's heel to the gluteal fold. This measurement would be appropriate for thigh-high stockings, not knee-high stockings.
C. Measure from the client's heel to the popliteal space. For knee-high stockings, measuring from the heel to the popliteal space (behind the knee) ensures the stockings fit properly without cutting off circulation or causing discomfort.
D. Measure the length of the client's feet. Foot length is not necessary for knee-high stockings, as their primary function is to apply compression from the ankle to the knee.
Correct Answer is D
Explanation
A. Nitroglycerin: Nitroglycerin is used to relieve chest pain by dilating coronary arteries and increasing blood flow. However, in the immediate setting of a suspected MI, oxygen is prioritized to ensure adequate oxygenation.
B. Aspirin: Aspirin is essential in the early treatment of MI to prevent further clot formation by inhibiting platelet aggregation, but oxygen would still come first if the client’s oxygenation is compromised.
C. Morphine: Morphine is used for pain relief and to reduce anxiety and oxygen demand on the heart. However, it is administered after ensuring oxygen supply.
D. Oxygen: Oxygen should be administered first in a suspected myocardial infarction to ensure the heart and tissues receive adequate oxygen, especially if the patient is hypoxic.
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