A client with unstable angina pectoris receives a prescription for nitroglycerin 0.4 mg sublingually PRN chest pain every 5 minutes x3. The prescription directions include leaving the medication at the bedside for self-administration. Which assessment finding should the practical nurse (PN) obtain first?
Number of tablets taken in past 24 hours.
Level of orientation and compliance.
Heart rate and blood pressure.
Hourly urinary output and daily weight.
The Correct Answer is B
A. While knowing the number of tablets taken is important for managing chest pain, it is secondary to ensuring that the client can safely administer the medication.
B. Assessing the client's level of orientation and compliance is crucial because the client needs to understand how and when to use the nitroglycerin properly. Misunderstanding or non-compliance could lead to ineffective treatment or potential harm.
C. Checking heart rate and blood pressure is important for assessing the effects of nitroglycerin, but before leaving the medication for self-administration, it is vital to ensure that the client understands how to use the medication.
D. Monitoring hourly urinary output and daily weight is not relevant to the immediate concern of ensuring safe and effective nitroglycerin self-administration.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Understanding the client’s current and previous sleep habits and cycles is the most foundational step for assessing sleep disturbances. This information provides a baseline from which the PN can identify patterns and deviations in the client’s sleep behavior.
B. While evening meal and snacking habits can affect sleep, they are secondary to understanding the client’s overall sleep habits and cycles. These habits are part of a broader assessment but not the initial focus.
C. Identifying symptoms resulting from sleep disturbances is important but follows after understanding the client’s sleep history. Symptoms are a result of disturbances, and their identification is based on a foundational understanding of sleep patterns.
D. Exploring new sleep routines the client is considering is part of the intervention phase but comes after understanding current sleep patterns and disturbances. The initial focus should be on gathering comprehensive sleep history.
Correct Answer is B
Explanation
A. A warm sleeping environment may exacerbate pruritus by increasing skin dryness and irritation. Cool, comfortable environments are generally better for clients with pruritus.
B. Keeping fingernails trimmed short helps prevent skin damage and infection caused by scratching. This is a practical and effective measure to manage pruritus.
C. Discouraging the use of skin lubricants is not advisable as they can help soothe and moisturize dry, itchy skin. Emollients and moisturizers are often recommended to manage pruritus.
D. Advising against any type of tub bath is not necessary. Instead, the use of lukewarm baths with added colloidal oatmeal or other soothing agents can help reduce pruritus.
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