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 C
Explanation
Choice A reason: Diet cola PO is not an appropriate recommendation for a client with a blood glucose of 30, because diet cola does not contain any sugar and will not raise the blood glucose level. Moreover, the client is lethargic and unable to follow commands, which means they may have difficulty swallowing and may aspirate the liquid.
Choice B reason: Dextrose 50% IV is a potential recommendation for a client with a blood glucose of 30, because it can rapidly increase the blood glucose level and reverse the symptoms of hypoglycemia. However, the nurse is unable to get an IV line started on the client, which makes this option impossible.
Choice C reason: Glucagon IM is the best recommendation for a client with a blood glucose of 30, because it can stimulate the liver to release glucose into the bloodstream and raise the blood glucose level. Glucagon can be given intramuscularly or subcutaneously, which does not require an IV access. Glucagon is usually given as an emergency treatment for severe hypoglycemia when the client is unconscious or unable to swallow.
Choice D reason: Insulin glargine SQ is not an appropriate recommendation for a client with a blood glucose of 30, because insulin glargine is a long-acting insulin that lowers the blood glucose level. Giving insulin to a client with hypoglycemia can worsen their condition and cause coma or death. ⁹
Correct Answer is ["1.1"]
Explanation
To calculate the amount of cefazolin that the nurse should add to the 50 mL of 0.9% sodium chloride, we can use the following steps:
Calculate the amount of cefazolin needed to prepare the solution:
- The concentration to be achieved is 225 mg/mL.
- The required dose is 250 mg.
Calculate the volume of cefazolin needed:
- 250 mg ÷ 225 mg/mL = 1.111... mL
- Rounded to the nearest tenth, the nurse should add 1.1 mL of cefazolin to the 50 mL of 0.9% sodium chloride.
Therefore, the nurse should add 1.1 mL of cefazolin to the 50 mL of 0.9% sodium chloride to prepare the solution for IV administration.
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