When should the nurse reassess a client after administering 0.4 mg nitroglycerin sublingual to a client with chest pain?
30 minutes
5 minutes
1 hour
15 minutes
The Correct Answer is B
Choice A reason: This is incorrect because 30 minutes is too long to wait for reassessing a client with chest pain. Nitroglycerin has a rapid onset of action and should relieve chest pain within 5 minutes. If not, the client may need another dose or emergency care.
Choice B reason: This is correct because 5 minutes is the appropriate time to reassess a client after administering nitroglycerin sublingual. The nurse should check the client's blood pressure, heart rate, and pain level. If the pain persists, the nurse should follow the protocol for giving another dose or calling for help.
Choice C reason: This is incorrect because 1 hour is too long to wait for reassessing a client with chest pain. Nitroglycerin has a short duration of action and may need to be repeated every 5 minutes for up to 3 doses. Waiting for an hour may put the client at risk of worsening cardiac ischemia or infarction.
Choice D reason: This is incorrect because 15 minutes is too long to wait for reassessing a client with chest pain. Nitroglycerin should have an effect within 5 minutes. If the pain is not relieved by then, the client may need another dose or emergency care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["31"]
Explanation
To calculate the IV flow rate in drops per minute (gtt/min), we can use the following steps:
Calculate the total number of minutes for the infusion:
8 hours × 60 minutes/hour = 480 minutes
Determine the total number of drops needed for the infusion:
The total volume to be infused is 1000 mL.
The drop factor is 15 gtt/mL.
1000 mL × 15 gtt/mL = 15000 gtt
Calculate the IV flow rate in drops per minute:
15000 gtt ÷ 480 min ≈ 31 gtt/min
Rounding to the nearest whole number, the nurse should set the IV flow rate to deliver 31 gtt/min.
Correct Answer is ["48"]
Explanation
To calculate the amount of gentamicin the nurse should administer in milliliters (mL) for a client who weighs 210 lb, we can use the following steps:
Given:
Client's weight: 210 lb
Gentamicin dose: 5 mg/kg
Available concentration: 10 mg/mL
Step 1: Convert the client's weight from pounds (lb) to kilograms (kg)
Client's weight in kg = Client's weight in lb / 2.2
Client's weight in kg = 210 lb / 2.2
Client's weight in kg ≈ 95.45 kg
Step 2: Calculate the total dose of gentamicin required
Total dose = Client's weight in kg × Gentamicin dose
Total dose = 95.45 kg × 5 mg/kg
Total dose = 477.25 mg
Step 3: Calculate the volume of gentamicin to be administered in mL
Volume = Total dose / Concentration
Volume = 477.25 mg / 10 mg/mL
Volume ≈ 47.725 mL
Rounding to the nearest whole number:
Volume ≈ 48 mL
Therefore, the nurse should administer approximately 48 mL of gentamicin via intermittent IV bolus to the client who weighs 210 lb.
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