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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: Droplet precautions are used for diseases that are transmitted through large respiratory droplets produced by coughing, sneezing, or talking. AIDS, caused by the Human Immunodeficiency Virus (HIV), is not transmitted through respiratory droplets, so droplet precautions are not necessary for a client with AIDS.

Choice B reason: Standard precautions are the primary strategy for the prevention of infection transmission and apply to all patients receiving care in hospitals, regardless of their diagnosis or presumed infection status. These precautions include hand hygiene, the use of personal protective equipment (PPE) like gloves and gowns, and safe injection practices. Since HIV/AIDS can be transmitted through blood and certain body fluids, standard precautions are essential when caring for clients with AIDS.

Choice C reason: Airborne precautions are used for diseases that are transmitted by small droplet nuclei that remain suspended in the air and can be widely dispersed by air currents within a room or over a long distance. HIV/AIDS is not transmitted through the airborne route, so airborne precautions are not indicated for clients with AIDS.

Choice D reason: Contact precautions are used for infections that are spread by direct contact with the patient or indirect contact with surfaces or patient care items. While HIV can be present in body fluids, it is not easily transmitted through casual contact. Therefore, contact precautions are not specifically required for clients with AIDS unless they have other conditions that warrant such precautions.

A. Rinse your mouth with hydrogen peroxide. B. Brush your teeth for 60 seconds twice daily. C. Floss your teeth gently following each meal. D. Wear your dentures only during meals. E. None F. None

Correct Answer is C

Explanation

Choice A: Rinse your mouth with hydrogen peroxide

Rinsing the mouth with hydrogen peroxide is not recommended for clients with mucositis. Hydrogen peroxide can be too harsh and may cause further irritation to the already sensitive mucosal lining. It is generally advised to use mild rinses such as saline or baking soda solutions.

Choice B: Brush your teeth for 60 seconds twice daily

While brushing is important, it should be done gently with a soft-bristled toothbrush, and the timing should be based on patient tolerance rather than a strict 60-second rule.

Choice C: Floss your teeth gently following each meal

Gentle flossing helps remove food particles and bacteria, reducing the risk of infection. However, if bleeding occurs, the patient should stop and consult a healthcare provider.

Choice D: Wear your dentures only during meals

Wearing dentures only during meals might be advisable for some clients with mucositis, as wearing them all day could irritate the inflamed oral tissues. However, it’s important for the dentures to fit properly and for the client to have periods of rest without the dentures to allow the oral tissues to heal.

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The nurse is instructing the client on the correct way to take nitroglycerin as needed for chest pain:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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