A nurse at a provider's office receives a telephone call from a client who reports nausea and has 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 take an antacid.

Advise the client to come into the office.

Instruct the client to call 911.

Answer and Explanation

The Correct Answer is D

A. Tell the client to take another nitroglycerin tablet in 15 minutes. Nitroglycerin can be taken every 5 minutes, up to three doses, for chest pain. Waiting 15 minutes to take another dose is too long and can delay necessary treatment.

B. Advise the client to take an antacid. Antacids are not appropriate for managing chest pain that may be related to angina or a myocardial infarction. This response may delay critical treatment.

C. Advise the client to come into the office. This would delay care in a potential emergency situation. If the client is experiencing unrelieved chest pain after taking nitroglycerin, immediate emergency care is necessary.

D. Instruct the client to call 911. Chest pain unrelieved by nitroglycerin is a sign of a possible myocardial infarction, which is a medical emergency. The client should call 911 immediately to receive urgent care.

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Correct Answer is B

Explanation

A. Keep the affected knee flexed. Flexing the knee for prolonged periods can impede venous return and increase the risk of thrombosis. The knee should be extended, not flexed.

B. Encourage increased fluid intake. Encouraging fluid intake helps to prevent dehydration, which is a risk factor for blood clot formation. Adequate hydration helps keep the blood less viscous and reduces the risk of DVT.

C. Massage the client's calf on the affected side. Massaging the calf could dislodge a clot if one is present, leading to serious complications such as a pulmonary embolism. This is contraindicated.

D. Promote bed rest for 5-10 days. Early ambulation and movement are key to preventing DVT after surgery. Prolonged bed rest increases the risk of DVT due to venous stasis.

A. "Nitroglycerin dilates cardiac blood vessels to deliver more oxygen to the heart." B. "Nitroglycerin relieves nausea and prevents vomiting, which could lead to aspiration." C. "Nitroglycerin acts as a bronchodilator to open small airways and decrease shortness of breath." D. "Nitroglycerin decreases chest pain by dissolving blood clots that are occluding the arteries."

Correct Answer is A

Explanation

A. "Nitroglycerin dilates cardiac blood vessels to deliver more oxygen to the heart." Nitroglycerin works by dilating the coronary arteries, increasing blood flow and oxygen delivery to the heart muscle, thereby reducing angina.

B. "Nitroglycerin relieves nausea and prevents vomiting, which could lead to aspiration." Nitroglycerin does not have an antiemetic function or impact nausea and vomiting.

C. "Nitroglycerin acts as a bronchodilator to open small airways and decrease shortness of breath." Nitroglycerin is not a bronchodilator. It does not act on the airways but instead works on blood vessels.

D. "Nitroglycerin decreases chest pain by dissolving blood clots that are occluding the arteries." Nitroglycerin does not dissolve blood clots. Thrombolytic agents are used for clot dissolution, not nitroglycerin.

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A nurse at a provider's office receives a telephone call from a client who reports nausea and has 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

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postoperative following a total knee replacement. Which of the following actions should the nurse implement to prevent deep vein thrombophlebitis?

Correct Answer is B

Explanation

nurse is caring for a client who is newly-admitted and has angina. The client asks the nurse, "Why am I taking nitroglycerin?" Which of the lowing responses should the nurse make?

Correct Answer is A

Explanation

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