The nurse is caring who presented with unstable angina. Before giving the client, a dose of sublingual nitroglycerin, which action should the nurse take?

Auscultate the client’s apical pulse for a full minute

Advise the client that vomiting is primary side effect

Check the client’s blood pressure

Obtain a STAT chest X-ray

Answer and Explanation

The Correct Answer is C

A. Auscultate the client’s apical pulse for a full minute:
While auscultating the apical pulse is important for certain cardiovascular conditions, it is not the primary action needed before administering sublingual nitroglycerin. The nurse's main priority is to assess the patient's blood pressure, as nitroglycerin can cause significant hypotension (a drop in blood pressure), and it is important to ensure the patient’s blood pressure is adequate before administration. If the blood pressure is too low, nitroglycerin should not be given.

B. Advise the client that vomiting is a primary side effect:
Vomiting is not a primary or common side effect of sublingual nitroglycerin. Nitroglycerin is more likely to cause headaches, dizziness, flushing, and hypotension. While it’s helpful to inform the patient about possible side effects, advising them that vomiting is a primary side effect could cause unnecessary concern or confusion.

C. Check the client’s blood pressure:
This is the correct action. Nitroglycerin works by dilating blood vessels, which can lower blood pressure. Before administering sublingual nitroglycerin, it is essential to check the client's blood pressure. If the client is hypotensive or has low blood pressure, nitroglycerin should be withheld, as it could further decrease blood pressure and worsen the patient’s condition. This is the priority nursing action to ensure the patient’s safety.

D. Obtain a STAT chest X-ray:
Obtaining a chest X-ray is not a priority action for a client with unstable angina before administering nitroglycerin. Chest X-rays are more useful for diagnosing conditions like pneumonia, pneumothorax, or other structural issues of the chest, but they are not immediately needed in the management of unstable angina. The most immediate concern is assessing the patient’s blood pressure before administering nitroglycerin.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A) "The test will use a catheter to assess for blocked coronary arteries": This statement is incorrect. An echocardiogram does not involve the use of a catheter. It is a non-invasive imaging test that uses sound waves (ultrasound) to create images of the heart's structure and function. Assessing for blocked coronary arteries typically requires a different procedure, such as a coronary angiogram, which involves the use of a catheter.

B) "The test can show how well your heart pumps blood.": This is the correct statement. An echocardiogram is primarily used to assess how well the heart is functioning, including how effectively it pumps blood. It can provide detailed images of the heart's chambers, valves, and blood flow, helping to evaluate conditions such as heart failure, valve dysfunction, and other structural issues that may impair the heart’s ability to pump blood efficiently.
C) "The test will show proteins in the blood from damaged heart muscle.": This statement is incorrect. An echocardiogram does not measure blood proteins or markers from damaged heart muscle. Blood tests, such as troponin levels, are used to detect proteins released from heart muscle after injury, such as in a heart attack. The echocardiogram focuses on the heart's structure and function, not the chemical markers in the blood.

D) "The test shows the electrical activity of the heart from multiple angles.": This statement is inaccurate. The electrical activity of the heart is assessed by an electrocardiogram (ECG or EKG), not an echocardiogram. An ECG records the heart's electrical signals, while an echocardiogram uses sound waves to visualize the heart's anatomical structure and function.

A. I will notify my doctor before taking any other medications’’ B. "I should talk to my doctor about other methods of contraception in addition to my current oral contraceptives. C. "I'll be glad when I can stop taking this medicine after my seizures are controlled’’ D. I have made an appointment to see my dentist next week.’’

Correct Answer is C

Explanation

A) "I will notify my doctor before taking any other medications:"
Phenytoin interacts with many medications, both prescription and over-the-counter. It is crucial for the client to inform their doctor before starting any new medications, including herbal supplements, as phenytoin may have significant drug interactions that could alter its effectiveness or increase the risk of side effects.

B) "I should talk to my doctor about other methods of contraception in addition to my current oral contraceptives:"
Phenytoin can decrease the effectiveness of oral contraceptives, leading to an increased risk of unintended pregnancy. It is important for clients to discuss alternative or additional methods of contraception, such as non-hormonal methods or alternative hormonal birth control, with their healthcare provider to prevent pregnancy while taking phenytoin.

C) "I'll be glad when I can stop taking this medicine after my seizures are controlled:"
Phenytoin is typically a lifelong medication for managing seizures, even if the seizures are well-controlled. Stopping the medication without a doctor's approval can lead to seizure recurrence. Seizure control does not always mean stopping medication, and clients need to understand the importance of continuing the prescribed treatment regimen, even after achieving stability.

D) "I have made an appointment to see my dentist next week:"
Phenytoin can cause gingival hyperplasia, which increases the need for regular dental checkups. It is recommended that clients taking phenytoin see a dentist regularly to manage this potential side effect and maintain oral health.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is caring who presented with unstable angina. Before giving the client, a dose of sublingual nitroglycerin, which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing a client for an echocardiogram. The client asks what the test can show Which of the following is a correct statement?

Correct Answer is B

Explanation

A nurse is performing discharge teaching for a client who has seizures and a new prescription for phenytoin, which of following statements by the client indicates a need for further teaching?

Correct Answer is C

Explanation

A nurse is providing teaching to a client who has seizures and a new prescription for phenytoin. Which of the following information should the nurse provide?

The nurse identifies which of the following as one of the primary nursing interventions for preventing surgical site infection?

A client is tested for human immunodeficiency virus (HIV) infection with an enzyme- linked immunosorbent assay (ELISA), and the test result & positive. What would the nurse tell the client?

A nurse is caring for a young female adult client who reports weakness, fatigue, and heavy menstrual periods. The client has a hemoglobin level of 6.9 g/dL. The nurse suspects which of the following types of anemia?

The nurse cares for a client who is a pale and reports frequent fatigue, weakness and dizziness. Which serum laboratory test result is the nurse’s priority for planning care?

The nurse is preparing to administer a shot of vitamin B12 to a client with low hemoglobin. The nurse knows that this medication is most indicative of which type of anemia?

The nurse is assigned to care for a client in traction. The nurse creates a plan of a care for the client and would include which action in the pian?

Before beginning a transfusion of packed red blood cells (PRBCs), which action by the nurse would be of highest priority to ensure patient safety?