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: This statement does not indicate a need for further instruction. It is recommended to take other medications at least 30 minutes after alendronate to ensure proper absorption of the drug.

Choice B reason: This statement indicates a need for further instruction. Alendronate should be taken with plain water, not milk. The calcium in milk can interfere with the absorption of alendronate.

Choice C reason: This statement is correct and does not indicate a need for further instruction. Patients are advised to stay upright for at least 30 minutes after taking alendronate to prevent esophageal irritation or reflux.

Choice D reason: This statement is correct and does not indicate a need for further instruction. Periodic bone density tests are necessary to monitor the effectiveness of alendronate therapy in treating osteoporosis.

A. Administer prescribed corticosteroids. B. Slow infusion rate and contact the provider. C. Lower the head of the bed to semi-Fowler's. D. Change infusion to lactated Ringer's and maintain rate.

Correct Answer is B

Explanation

Choice A reason : Administering corticosteroids is not the first-line action for dyspnea related to fluid overload or other causes of respiratory distress in this context.

Choice B reason : Slowing the infusion rate is appropriate when there are signs of fluid overload, such as dyspnea and hypertension. Contacting the provider is crucial for further assessment and management, which may include diuretics or other interventions.

Choice C reason : Lowering the head of the bed to semi-Fowler's may provide some relief for dyspnea, but it does not address the potential cause, which in this case could be fluid overload.

Choice D reason : Changing the infusion to lactated Ringer's would not be appropriate if the client is experiencing symptoms of fluid overload. The type of fluid is less important than the volume and rate of administration in this scenario.

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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

A nurse is reinforcing teaching with a client who has osteoporosis and is prescribed (Fosamax) alendronate 70 mg PO weekly. Which of the following statements by the client indicates a need for further instruction?

Correct Answer is B

Explanation

A nurse is caring for a client who is receiving a 0.9% sodium chloride via IV infusion. The client has become dyspneic with a blood pressure of 140/100 mm Hg, a fluid intake of 960 mL, and an output of 300 mL in the past 12 hours. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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