A client with angina pectoris is experiencing chest pain that radiates down the left arm. The nurse administers a sublingual nitroglycerin tablet to the client. The client's pain is unrelieved, and the nurse determines that the client needs another nitroglycerin tablet. Which cue is most important for the nurse to check before administering the medication?
Temperature
Oxygen saturation
Blood pressure
Apical pulse rate
The Correct Answer is C
A. Temperature is not directly related to the effects of nitroglycerin or the client’s need for additional doses.
B. While oxygen saturation is important, it does not directly influence the decision to administer nitroglycerin, which primarily works to relieve chest pain by dilating coronary arteries and reducing myocardial oxygen demand.
C. Nitroglycerin is a vasodilator that can lower blood pressure. It is crucial to check the client’s blood pressure before administering another dose of nitroglycerin because excessive drops in blood pressure can lead to dizziness, fainting, or other complications. If the blood pressure is already low, further administration may be contraindicated.
D. Apical pulse rate is important to monitor but is not the most critical cue in this scenario. Nitroglycerin primarily affects blood pressure and coronary circulation rather than directly influencing heart rate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Troponins (specifically troponin I and T) are proteins released when the heart muscle is damaged. They are the most specific and sensitive markers for myocardial injury, especially in diagnosing a myocardial infarction (MI).
B. Creatine kinase (CK) is an enzyme found in various tissues, including the heart. CK-MB is a cardiac isoenzyme, but it is not as specific for myocardial injury as troponins. It can also be elevated in other conditions like muscle injury.
C. Homocysteine (Hcy) is an amino acid that can increase the risk of cardiovascular disease but does not serve as an immediate marker for myocardial damage.
D. Myoglobin is an early marker of muscle injury, but it lacks specificity for myocardial damage as it can also rise in skeletal muscle injury, making it less reliable than troponins.
Correct Answer is B
Explanation
A. A troponin level will confirm myocardial injury but should be done after an ECG, as the ECG provides immediate information on the condition.
B. The first action in a chest pain situation is to obtain an ECG to assess for myocardial infarction or other cardiac abnormalities. The ECG provides immediate information about the heart's electrical activity and can help identify whether the chest pain is related to a cardiac event.
C. Insertion of a peripheral IV is important for administering medications and fluids, but it is not as urgent as obtaining an ECG to evaluate the patient's heart.
D. A chest X-ray is useful for other potential diagnoses (e.g., pulmonary embolism or pneumothorax) but is not the first step in diagnosing a myocardial event.
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