A client with angina pectoris is receiving sublingual nitroglycerin for chest pain relief. After administering the medication, what should the nurse instruct the client to do?
Lie down in bed and rest for at least 30 minutes.
Monitor blood pressure and heart rate every 15 minutes.
Avoid drinking water or any fluids for an hour.
Sit or lie down and avoid sudden position changes.
The Correct Answer is D
A) This choice is incorrect because while rest is essential during an angina episode, lying down in bed for an extended period is not necessary after administering nitroglycerin.
B) This choice is incorrect because monitoring blood pressure and heart rate every 15 minutes is not a standard nursing intervention after nitroglycerin administration. Monitoring vital signs as needed for the client's condition is appropriate.
C) This choice is incorrect because there is no need for the client to avoid drinking water or fluids after taking sublingual nitroglycerin.
D) This choice is correct. After taking sublingual nitroglycerin for chest pain relief, the client should sit or lie down and avoid sudden position changes. Nitroglycerin can cause systemic vasodilation and may lead to orthostatic hypotension, increasing the risk of dizziness or falls if the client stands up abruptly. Taking a seated or lying position reduces this risk and allows the medication to work effectively to relieve chest pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) This choice is incorrect because chest pain caused by an irregular heart rhythm is more characteristic of arrhythmias, not angina pectoris.
B) This choice is correct. Angina pectoris is caused by the narrowing of the coronary arteries due to atherosclerotic plaques, leading to reduced blood flow to the heart muscle during periods of increased demand (e.g., physical exertion, stress).
C) This choice is incorrect because inflammation in the lining of the heart is associated with conditions like pericarditis or myocarditis, not angina pectoris.
D) This choice is incorrect because chest pain caused by the heart muscle overworking is more typical of conditions like heart failure, not angina pectoris.
Correct Answer is D
Explanation
A) This choice is incorrect because myoglobin is a cardiac biomarker that may be elevated in MI, but it lacks specificity and can also be elevated in other conditions like skeletal muscle injury.
B) This choice is incorrect because C-reactive protein (CRP) is an inflammatory marker and is not specific to MI. It may be elevated in various inflammatory conditions.
C) This choice is incorrect because brain natriuretic peptide (BNP) is a biomarker associated with heart failure and is not specific to diagnosing MI.
D) This choice is correct. Troponin is the most specific biomarker for diagnosing MI. Elevated troponin levels in the blood indicate cardiac muscle damage, making it a reliable marker for myocardial infarction. Troponin levels rise shortly after the onset of MI and remain elevated for several days, making it valuable in both early and delayed MI detection.
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