A nurse is caring for a patient with a diagnosis of myocardial infarction (MI), who reports chest pain 8/10. The nurse administers a sublingual nitroglycerin tablet as prescribed. After 5 minutes, the chest pain is 6/10. What action does the nurse take first?
Check the blood pressure
Start a nitroglycerin IV infusion
Administer another nitroglycerin tablet
Increase the flow rate of the oxygen to 3L via NC
The Correct Answer is A
A. Check the blood pressure: Before administering additional doses of nitroglycerin, it is essential to assess the patient’s blood pressure. Nitroglycerin is a potent vasodilator, and repeated dosing can cause hypotension, which could worsen myocardial perfusion or precipitate shock. Blood pressure assessment ensures safe titration of therapy.
B. Start a nitroglycerin IV infusion: Initiating an IV nitroglycerin infusion is an advanced intervention that may be required if sublingual therapy fails, but it should not be started until the patient’s vital signs are assessed and the provider is consulted. Premature escalation could risk severe hypotension.
C. Administer another nitroglycerin tablet: Giving another tablet may be appropriate if pain persists, but it must be guided by blood pressure and clinical status. Administering additional doses without assessment could dangerously lower blood pressure or reduce coronary perfusion.
D. Increase the flow rate of the oxygen to 3L via NC: Oxygen therapy can support oxygenation in MI, but increasing flow should not be the first action. Oxygen alone does not directly relieve ischemic chest pain, and priority interventions focus on ensuring safe administration of nitroglycerin and monitoring hemodynamics.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Check the blood pressure: Before administering additional doses of nitroglycerin, it is essential to assess the patient’s blood pressure. Nitroglycerin is a potent vasodilator, and repeated dosing can cause hypotension, which could worsen myocardial perfusion or precipitate shock. Blood pressure assessment ensures safe titration of therapy.
B. Start a nitroglycerin IV infusion: Initiating an IV nitroglycerin infusion is an advanced intervention that may be required if sublingual therapy fails, but it should not be started until the patient’s vital signs are assessed and the provider is consulted. Premature escalation could risk severe hypotension.
C. Administer another nitroglycerin tablet: Giving another tablet may be appropriate if pain persists, but it must be guided by blood pressure and clinical status. Administering additional doses without assessment could dangerously lower blood pressure or reduce coronary perfusion.
D. Increase the flow rate of the oxygen to 3L via NC: Oxygen therapy can support oxygenation in MI, but increasing flow should not be the first action. Oxygen alone does not directly relieve ischemic chest pain, and priority interventions focus on ensuring safe administration of nitroglycerin and monitoring hemodynamics.
Correct Answer is C
Explanation
A. Change the chest tube drainage system: Replacing the entire drainage system may be necessary if it is malfunctioning, but this is not the first action. Immediate assessment is required to determine the cause of the sudden decrease in drainage before taking corrective steps.
B. Increase the suction pressure on the chest tube drainage system: Adjusting suction without understanding the reason for decreased drainage could worsen the situation or create unnecessary negative pressure. Suction adjustments should only be made after identifying the underlying issue.
C. Assess the tubing of the chest tube and drainage system: The first action is to inspect the tubing for kinks, clots, disconnections, or obstructions, which are the most common causes of sudden decreased drainage. Ensuring the system is intact and functional preserves lung re-expansion and prevents complications.
D. Call the provider immediately to report the decrease in drainage: Reporting to the provider is important if a problem is identified, but the nurse must first assess and gather information about the situation. Immediate assessment provides critical data for accurate reporting and timely intervention.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
