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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Palpating the brachial artery before inflating the blood pressure cuff is a correct technique to locate the artery and ensure accurate blood pressure measurement.
B. Counting respirations while palpating the radial pulse is a correct technique as it minimizes the risk of the client altering their breathing pattern.
C. Asking the client to relax their arm before taking the blood pressure is an appropriate step to ensure an accurate measurement.
D. Inserting a thermometer into the sublingual pocket after the client sips water can affect the accuracy of the temperature reading, as water can alter the temperature measurement.
Correct Answer is ["B","E"]
Explanation
A. Urinalysis is not directly related to evaluating the effectiveness of an antibiotic for a respiratory tract infection.
B. Sputum culture and sensitivity are crucial in determining the specific bacteria causing the infection and assessing the antibiotic’s effectiveness in eradicating the pathogen.
C. Prothrombin time is related to blood clotting and is not relevant to monitoring the effectiveness of an antibiotic for a respiratory infection.
D. Serum potassium is important for monitoring electrolyte balance but does not directly evaluate the effectiveness of an antibiotic.
E. White blood cell count is a key indicator of infection and inflammation; a decrease in WBC count suggests that the antibiotic is effectively combating the infection.
F. Capillary glucose monitoring is more relevant to diabetic management and is not used to evaluate antibiotic effectiveness.
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