The nurse is instructing the client on the correct way to take nitroglycerin as needed for chest pain:
Two tablets PO (by mouth) every 15 minutes.
One tablet SL (sublingual) every 15 minutes, up to 5 times.
One tablet PO (by mouth) every one hour, up to 5 times.
One tablet SL (sublingual) every 5 minutes, up to 3 times.
The Correct Answer is D
Choice A reason: Taking two tablets PO every 15 minutes is not the standard protocol for nitroglycerin administration for chest pain. This method could lead to an overdose and significant hypotension (low blood pressure), which can be dangerous.
Choice B reason: One tablet SL every 15 minutes, up to 5 times, is also not the standard protocol. While sublingual administration is correct, the frequency and the total number of doses are higher than recommended, which could result in adverse effects such as headache, dizziness, or a severe drop in blood pressure.
Choice C reason: One tablet PO every one hour, up to 5 times, is not a recommended method for acute chest pain relief from angina. Oral administration does not provide the rapid onset of action required for acute angina relief.
Choice D reason: One tablet SL every 5 minutes, up to 3 times, is the correct protocol for nitroglycerin administration when experiencing chest pain due to angina. If pain persists after the first dose, the patient can take a second dose after 5 minutes, and if needed, a third dose after another 5 minutes. If chest pain continues after three doses in 15 minutes, emergency medical help should be sought immediately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: The Mantoux skin test, also known as the tuberculin skin test, measures the immune response to the tuberculin purified protein derivative injected into the skin. An induration of less than 1 mm is not considered a positive result. However, the size of the induration in the Mantoux test does not indicate whether the person is infectious or not.
Choice B reason: Negative sputum cultures for acid-fast bacillus (AFB) are a strong indication that the client is no longer infectious. Pulmonary tuberculosis is diagnosed and monitored by the presence of AFB in the sputum. When the sputum cultures are negative, it suggests that the client is not excreting the bacteria and is less likely to spread the infection to others.
Choice C reason: While no longer coughing up blood-tinged sputum is a sign of clinical improvement, it does not necessarily mean that the client is no longer infectious. The absence of blood in the sputum may indicate reduced inflammation or healing of lung tissue, but the client could still be capable of transmitting tuberculosis if AFB is present in the sputum.
Choice D reason: The Quantiferon-TB Gold test is a blood test that measures the immune response to Mycobacterium tuberculosis antigens. A positive result indicates that the person's immune system has been exposed to the bacteria, but it does not determine if the person is infectious. The term "positive (negative)" is contradictory and does not provide clear information about the client's infectious status.
Correct Answer is D
Explanation
Choice A reason: Petechiae on the chest are small, red or purple spots caused by bleeding into the skin and may be associated with various conditions, including infections. However, they are not a common finding in meningitis. Meningitis typically presents with symptoms related to inflammation of the meninges, the protective membranes covering the brain and spinal cord.
Choice B reason: Bradycardia, which is a slower than normal heart rate, is not a typical symptom of meningitis. While meningitis can affect various bodily functions, the classic symptoms are fever, headache, and neck stiffness, not changes in heart rate.
Choice C reason: Intermittent headache could be associated with meningitis, but the headaches that accompany meningitis are usually constant and severe due to the inflammation of the meninges. They are not typically described as intermittent.
Choice D reason: Photophobia, or light sensitivity, is a common finding in meningitis. The inflammation of the meninges can lead to an increased sensitivity to light, causing discomfort or pain when the patient is exposed to bright lights. This symptom, along with headache, neck stiffness, and fever, helps to distinguish meningitis from other conditions.
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