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A nurse assesses a client after administering the first dose of a nitrate. The client reports a headache. What action would the nurse take?

Instruct the client to drink water.

Hold the next dose.

Initiate oxygen therapy.

Administer PRN acetaminophen.

Answer and Explanation

The Correct Answer is D

A. Drinking water is not likely to alleviate the headache caused by the nitrate.

B. Holding the next dose is not necessary unless the headache becomes severe or is associated with other symptoms.

C. Initiating oxygen therapy is unnecessary for a headache caused by nitrate use.

D. A headache is a common side effect of nitrate administration due to the vasodilation effect. Administering PRN acetaminophen can help relieve the headache.

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Correct Answer is B

Explanation

A. The excitement of family does not indicate an infection risk. Emotional support can aid recovery.

B. Handling cat litter, which can contain bacteria, is a potential source of infection. Given the client's sternal wound, exposure to such bacteria increases the risk of infection, including sepsis.

C. Attending a party may present social interaction risks, but it is not as directly related to infection risk as handling cat litter.

D. Having the water turned on does not pose a significant risk for infection or sepsis.

A. 56-year-old client with chronic stable angina who is due to receive a dose of nifedipine. B. 59-year-old with unstable angina who has just returned to the unit after having a heart catheterization with balloon angioplasty. C. 65-year-old who had a myocardial infarction (MI) 4days ago and is anxious about the planned discharge. D. Client who is post coronary artery bypass, with potassium 4.2 mEq/L.

Correct Answer is B

Explanation

A. A stable client with chronic angina is not in immediate danger, and the scheduled dose of nifedipine is not an urgent priority.

B. The client with unstable angina who has just undergone a heart catheterization with balloon angioplasty requires immediate assessment for complications such as bleeding, clot formation, or re-occlusion of the artery.

C. The 65-year-old post-MI client is stable, and while their anxiety is important to address, it is not an immediate concern compared to other clients.

D. The client post-coronary artery bypass with a potassium level of 4.2 mEq/L is stable and does not require urgent intervention.

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A nurse assesses a client after administering the first dose of a nitrate. The client reports a headache. What action would the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is being discharged home after a large myocardial infarction and subsequent coronary artery bypass grafting surgery. The client's sternal wound has not yet healed. What statement by the client most indicates a higher risk of developing sepsis after discharge?

Correct Answer is B

Explanation

After receiving change-of-shift report about the following four clients, which client should the nurse assess first?

Correct Answer is B

Explanation

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