Which nursing action is most important after administering nitroglycerin sublingually?

Monitoring the client’s respiratory rate and effort.

Warning the client to lie still to prevent a headache.

Determining whether chest pain has been relieved.

Verifying that the sublingual tablet produced a tingling sensation.

Answer and Explanation

The Correct Answer is C

Determining whether chest pain has been relieved. This is because nitroglycerin is a medication that is used to treat chest pain caused by cardiac origin or acute pulmonary edema. The main action of nitroglycerin is to relax and dilate the blood vessels, which reduces the workload of the heart and improves blood flow to the heart muscle.

Therefore, the most important nursing action after administering nitroglycerin sublingually is to assess if the chest pain has subsided or not.

Choice A is wrong because monitoring the client’s respiratory rate and effort is not the most important action after giving nitroglycerin. Although nitroglycerin can cause hypotension and bradycardia, which may affect the respiratory status, these are side effects that can be managed and are not life-threatening as chest pain.

Choice B is wrong because warning the client to lie still to prevent a headache is not a priority after giving nitroglycerin. Nitroglycerin can cause headache as a side effect, but this can be treated with analgesics and does not require the client to lie still. Moreover, lying still may increase the risk of venous thromboembolism in a client with peripheral vascular disease.

Choice D is wrong because verifying that the sublingual tablet produced a tingling sensation is not essential after giving nitroglycerin.

Although some sublingual tablets may produce a tingling sensation, this is not a reliable indicator of the drug’s effectiveness

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Correct Answer is B

Explanation

This is because the nurse’s reply does not address the client’s fear of radiation therapy, but rather provides factual information that may not be relevant or helpful to the client.

The nurse is not using a therapeutic communication technique, such as reflecting, exploring, or validating the client’s feelings.

Instead, the nurse is shutting down the communication and missing an opportunity to learn more about the client’s concerns and needs.

Choice A is wrong because the nurse is not confronting a painful subject, but rather avoiding it.

The nurse is not acknowledging the client’s fear or inviting the client to talk more about it.

Choice C is wrong because the nurse is not recognizing that the client needs information, but rather assuming that the client does.

The nurse is not asking the client what he or she wants to know about radiation therapy, but rather telling the client what he or she should know.

Choice D is wrong because the nurse is not perceiving that the client is ready to hear more about the treatment, but rather imposing information on the client.

The nurse is not assessing the client’s readiness to learn, but rather giving unsolicited advice.

A. “The risk of getting schizophrenia is low, and most people with a close relative with the condition will not develop it themselves.”. B. “Schizophrenia is caused by genetic factors and your children will develop the disease ten times more often than the general public.”. C. “There is a 50% chance that your child will be born with schizophrenia, so keep them out of crowded places and high anxiety situations.”. D. “Females with schizophrenia are infertile and unable to carry a full-term pregnancy, but most of the people who are affected are male.”.

Correct Answer is A

Explanation

Schizophrenia is a disorder that has genetic risk factors, but is not caused by a single gene. The risk of developing schizophrenia is higher if you have a close relative with the disorder, but it is not certain. The risk varies depending on the degree of relatedness and the number of genes involved. The heritability of schizophrenia, which measures how much of the risk is due to genetic factors, is estimated to be between 60% to 80%.

Choice B is wrong because it exaggerates the risk of schizophrenia for children of affected parents. The risk is about 10%, not 10 times more than the general public.

Choice C is wrong because it gives a false and misleading statistic.

There is no 50% chance that a child will be born with schizophrenia, and there is no evidence that crowded places and high anxiety situations can cause the disorder.

Choice D is wrong because it is based on false and outdated stereotypes. Females with schizophrenia are not infertile and can carry a full-term pregnancy, but most of the people who are affected are male.

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Which nursing action is most important after administering nitroglycerin sublingually?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client says to a nurse, “I’m afraid of radiation therapy.” The nurse replies, “Radiation kills the cancer cells.” Which statement best describes the nurse?

Correct Answer is B

Explanation

A client newly diagnosed with schizophrenia asks the nurse “Will I pass this disease on to my children?” What is the best response?

Correct Answer is A

Explanation

Which nursing intervention would best assist a hospitalized client to maintain self-esteem?

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Which of the following assessments is the priority for a toddler who is diagnosed with fetal alcohol syndrome?

When a client has a nursing diagnosis of Ineffective Coping, which nursing interventions would best meet the desired outcome of demonstrating appropriate coping strategies? (Select all that apply).

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Which action should a nurse perform when administering an intramuscular injection via the Z- track method?

A health care provider prescribes one ounce of an elixir medication for a client. How many milliliters (mL) of medication should the nurse instruct the client to take during discharge teaching?