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 D

Explanation

Illness in one family member can affect the other family members. This is because family-centered nursing care recognizes that the family is the basic unit of society and that each member's health influences the whole family's health. Family-centered nursing care also involves collaborating with the family to provide care that meets their needs, preferences, and values.

Choice A is wrong because the nurse does not provide family-centered nursing care to avoid the client’s loneliness. Loneliness is a psychosocial need, not a physiologic one, and it can be addressed by other means than involving the family.

Choice B is wrong because the client’s compliance with medical instructions is not the primary goal of family-centered nursing care. Compliance is influenced by many factors, such as motivation, education, culture, and trust, and it may not always depend on the family’s involvement.

Choice C is wrong because the family’s willingness to listen to instructions is not the main reason for providing family-centered nursing care. The nurse should respect the family’s autonomy and decision-making, and not impose instructions that may conflict with their beliefs or values.

A. “It wouldn’t have mattered what you had worn.”. B. “The current styles are an invitation to disaster.”. C. “Never mind about blame. D. That will be determined by the court.”.

Correct Answer is A

Explanation

“It wouldn’t have mattered what you had worn.” This response by a nurse is appropriate because it validates the client’s feelings and helps to reduce self-blame. It also conveys that rape is not caused by the victim’s clothing or behavior, but by the perpetrator’s violence and lack of respect.

Choice B. “The current styles are an invitation to disaster.” is wrong because it implies that the client is responsible for the rape and that she could have prevented it by dressing differently. This response is judgmental and insensitive, and may increase the client’s guilt and shame.

Choice C. “Never mind about blame.

That will be determined by the court.” is wrong because it dismisses the client’s feelings and does not address her emotional needs.

It also suggests that the nurse does not believe the client or support her. This response may make the client feel isolated and distrustful.

Choice D. “Some people don’t have very good self-control.

We have to help them all we can.” is wrong because it excuses the perpetrator’s behavior and shifts the blame to the victim.

It also implies that rape is a result of sexual desire, rather than an act of violence and domination. This response may make the client feel powerless and helpless.

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Which nursing action is most important after administering nitroglycerin sublingually?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When providing nursing care to a client, the nurse provides family-centered nursing care. What is the best rationale for this nursing action?

Correct Answer is D

Explanation

A client in the emergency department who has been raped says repeatedly, “if only I hadn’t worn that sexy dress.” Which response by a nurse is appropriate?

Correct Answer is A

Explanation

Which statement made by a client taking nitroglycerin as needed (prn) indicates understanding of the instructions for safe use of this drug?

Which outcome is expected for a client who has a diagnosis of constipation? The client:.

A male client weighing 175 pounds is to receive an intramuscular injection into his deltoid of two milliliters (2 mL) of a viscous fluid. Which needle size should a nurse use?

A client has been treated for hypertension. What blood pressure reading indicates to the nurse that the treatment is effective?

A client with difficult venous access has an intravenous insertion site located at the bend of the wrist. Which action would be most appropriate for a nurse to take?

A nurse finds an adult client lying unconscious & unresponsive on the bathroom floor. Which action should the nurse take first?

A nurse is getting a client out of bed to ambulate for the first time. The client is pale, diaphoretic, has a pulse of 100/minute, and says, “I feel weak. Let me sit on the side of the bed for a minute.” What finding should the nurse document?