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 C

Explanation

A. Measure the client's ankle circumference. This is a correct action, as the ankle circumference is necessary to ensure that the stockings fit snugly and provide the proper amount of compression to prevent venous stasis.

B. Measure from the client's heel to the gluteal fold. This measurement would be appropriate for thigh-high stockings, not knee-high stockings.

C. Measure from the client's heel to the popliteal space. For knee-high stockings, measuring from the heel to the popliteal space (behind the knee) ensures the stockings fit properly without cutting off circulation or causing discomfort.

D. Measure the length of the client's feet. Foot length is not necessary for knee-high stockings, as their primary function is to apply compression from the ankle to the knee.

A. Emboli B. A heart murmur C. Petechiae D. Fever

Correct Answer is A

Explanation

A. Emboli: Emboli can form as vegetations break off from the heart valves and travel to other parts of the body, causing complications such as stroke, pulmonary embolism, or organ infarction.

B. A heart murmur: A heart murmur is a common symptom of infective endocarditis but not a complication. It results from valve damage caused by the infection.

C. Petechiae: Petechiae are a manifestation of infective endocarditis, not a complication. They occur due to the damage to blood vessels by emboli or infection.

D. Fever: Fever is a common sign of infective endocarditis due to the ongoing infection but is not considered a complication.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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