Which patient statement indicates that the nurse’s teaching about sublingual nitroglycerin (Nitrostat) has been effective?
“I can expect nausea as a side effect of nitroglycerin.”.
“I will call an ambulance if I have pain after taking 3 nitroglycerin 5 minutes apart.”.
“Nitroglycerin helps prevent a clot from forming and blocking blood flow to my heart.”.
“I should only take nitroglycerin when I have chest pain.”. .
The Correct Answer is B
The statement “I will call an ambulance if I have pain after taking 3 nitroglycerin 5 minutes apart” indicates that the patient understands the correct use of sublingual nitroglycerin (Nitrostat). If chest pain is not relieved after a total of 3 tablets or sprays, this is an emergency situation and medical help should be sought immediately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Redness on both sides of the sternal incision could indicate a normal inflammatory response post-surgery or could be a sign of infection. However, it is not the most crucial observation to report in the context of a patient who has undergone coronary artery bypass grafting using a right radial artery graft.
Choice B rationale
Fine crackles heard at both lung bases could indicate fluid accumulation in the lungs, possibly due to heart failure or pneumonia. While this is a significant finding that requires further investigation, it is not the most crucial observation in this specific context.
Choice C rationale
Complaints of incisional chest pain are common after coronary artery bypass grafting. Pain management is an important part of post-operative care, but this symptom is not the most crucial to report in this context.
Choice D rationale
Pallor and weakness of the right hand could indicate compromised blood flow to the hand, which is a serious complication considering the right radial artery was used for the graft. This could lead to ischemia and tissue damage in the hand, thus it is the most crucial observation to report to the healthcare provider.
Correct Answer is C
Explanation
Choice A rationale
Heberden’s nodes are bony swellings that occur at the distal interphalangeal finger joint, a sign of osteoarthritis. They are not associated with infective endocarditis (IE).
Choice B rationale
Bouchard’s nodes are similar to Heberden’s nodes but occur at the proximal interphalangeal finger joint. They are also a sign of osteoarthritis and not associated with IE.
Choice C rationale
Janeway lesions are flat, painless, red or purple spots on the palms of the hands or the soles of the feet. They are associated with IE and are caused by septic emboli which are small clots filled with bacteria. These emboli can lodge in small blood vessels, causing these characteristic lesions.
Choice D rationale
Tophi are hard, uric acid deposits under the skin. They are a sign of chronic gout, not IE.
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