A nurse at a provider's office receives a phone call from a client who reports nausea and unrelieved chest pain after taking a nitroglycerin tablet 5 min ago. Which of the following is an appropriate response by the nurse?

Tell the client to take another nitroglycerin tablet in 15 min.

Advise the client to come to office.

instruct the client to call 911.

Tell the client to take an antacid

Answer and Explanation

The Correct Answer is C

A. Taking another nitroglycerin tablet without medical supervision is inappropriate and can lead to unsafe drops in blood pressure. This situation requires immediate evaluation by emergency services.

B. Advising the client to come to the office is not appropriate because the client needs immediate emergency care, which cannot be provided in a typical provider’s office.

C. Nitroglycerin is typically used to relieve chest pain from angina, but if the pain persists after taking it, this may indicate a myocardial infarction (MI). The client should call 911 immediately for emergency medical care as chest pain not relieved by nitroglycerin is a critical sign.

D. Antacids are not appropriate for chest pain associated with possible MI, as this pain is not due to acid reflux. Immediate medical intervention is necessary.

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Correct Answer is B

Explanation

A. A decrease in LDL cholesterol is a desired effect of simvastatin and does not indicate a problem.

B. Generalized muscle aches are a significant concern for patients on statin medications, such as simvastatin. This can be indicative of a serious side effect called rhabdomyolysis, a condition where muscle tissue breaks down and can lead to kidney damage. This should be communicated to the healthcare provider immediately for further evaluation and possible discontinuation of the medication.

C. Nausea when taking the medication on an empty stomach is a common side effect and may be addressed with guidance on when to take the medication.

D. Clear, light yellow urine is normal and does not require further action.

A. Temperature B. Oxygen saturation C. Blood pressure D. Apical pulse rate

Correct Answer is C

Explanation

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.

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A nurse at a provider's office receives a phone call from a client who reports nausea and unrelieved chest pain after taking a nitroglycerin tablet 5 min ago. Which of the following is an appropriate response by the nurse?

Nursing Test Bank

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Correct Answer is B

Explanation

Correct Answer is C

Explanation

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