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

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

The nurse should make the statement “The client has hypoxemia after 10 minutes on a rebreather mask.” first. This is because SBAR (Situation- Background-Assessment-Recommendation) is a communication tool that helps provide essential, concise information, usually during crucial situations. The first component of SBAR is Situation, which is a concise statement of the problem.

The nurse should state the most urgent and relevant problem first, which is the client’s hypoxemia.

Choice A is wrong because it is not a clear statement of the situation.

It is vague and does not provide specific information about the client’s condition or vital signs.

It also expresses the nurse’s feeling rather than an objective assessment.

Choice C is wrong because it is part of the Assessment component of SBAR, not the Situation.

It provides numerical data about the client’s blood gas analysis, but it does not state the problem or the reason for calling the healthcare provider.

Choice D is wrong because it is part of the Background component of SBAR, not the Situation.

It provides pertinent and brief information related to the situation, such as the client’s medical history and diagnosis, but it does not state the current problem or concern.

Normal ranges for blood gas analysis are:

PaO2: 80-100 mmHg
PaCO2: 35-45 mmHg
HCO3: 22-26 mEq/L

Hypoxemia is defined as a low level of oxygen in the blood, usually below 60 mmHg.

A. “I don’t know because I am off duty now and I think you need to ask the nurse coming on this shift.”. B. “That is privileged, confidential information and I can’t discuss it with you now.”. C. “Why don’t we step off the elevator to discuss this in a more private area?”. D. “The client was stable before I left 30 minutes ago, but had to be restrained for agitation.”.

Correct Answer is C

Explanation

The nurse should respect the client’s privacy and confidentiality by not discussing the client’s condition in a crowded elevator, even with the health care provider. The nurse should suggest a more private area to have the conversation.

Choice A is wrong because it shows a lack of professionalism and accountability. The nurse should be able to provide a brief update on the client’s status to the health care provider, even if the nurse is off duty.

Choice B is wrong because it implies that the healthcare provider does not have the right to access the client’s information, which is not true. The health care provider is part of the health care team and has a legitimate need to know the client’s condition.

Choice D is wrong because it violates the client’s privacy and confidentiality by disclosing sensitive information in front of other people. The nurse should not share any details about the client’s condition or treatment without the client’s consent or unless it is necessary for the client’s care.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Which nursing action is most important after administering nitroglycerin sublingually?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse calls the healthcare provider using SBAR Communication. Which statement should the nurse make first?

Correct Answer is B

Explanation

At the end of the shift, a nurse enters a crowded elevator and is standing near a client’s health care provider. Which response of the nurse is most appropriate when the health care provider asks, “How is my client in room 913 doing?”.

Correct Answer is C

Explanation

For a client who is crying and seems agitated after major abdominal surgery, which action should a nurse take to establish a nursing diagnosis of pain related to an abdominal incision?

Which is the most appropriate action when obtaining a sterile urine specimen from an indwelling urinary catheter?

Which nursing diagnosis is priority for a client who has had vomiting and diarrhea for the past three days?

Which response by the client indicates that medication instruction by the RN has been effective?

Which statement, if made by a client diagnosed with sleep disturbance, should a nurse evaluate as correct understanding of the plan of care to improve sleep patterns?

The client’s 24-hour urine output is 750 mL and an amber color, oral intake is 1700 mL, and the weight has increased 3 kilograms in 2 days. The client is irritable and states “I have a headache.” Which laboratory value most correlates with these signs and symptoms?

An 82-year-old client was admitted to the hospital on isolation precautions 3 days ago for C diff. The client begins to demonstrate irritability, confusion, and paranoia. Which of the following is the best reason for the assessment findings?

A nurse identifies that a medication is ordered for the client as twice the regular dosage. What action should the nurse take?