A nurse is providing teaching to a client who has angina pectoris and a new prescription for nitroglycerin sublingual tablets. Which of the following statements by the client indicates an understanding of the teaching?
"I'll dial 911 if I still have pain after taking 4 nitroglycerin tablets over a 20-minute period."
"I'll dial 911 if 1 nitroglycerin tablet does not relieve my pain, and then take up to 2 more tablets 5 minutes apart while waiting."
“I’ll dial 911 when I have pain and then take the nitroglycerin tablets."
"I'll dial 911 if I still have pain after taking 3 nitroglycerin tablets 5 minutes apart."
The Correct Answer is D
A. Taking 4 nitroglycerin tablets is incorrect. The maximum dose is 3 tablets, taken 5 minutes apart. If chest pain persists after the third dose, the client should seek emergency help.
B. Calling 911 after only one dose is incorrect. The correct protocol is to take up to three doses before seeking emergency assistance unless symptoms worsen rapidly.
C. Calling 911 immediately before taking nitroglycerin is incorrect. The client should attempt to relieve the chest pain with nitroglycerin before calling for emergency help.
D. Calling 911 if pain persists after taking 3 nitroglycerin tablets 5 minutes apart is correct. Persistent chest pain despite nitroglycerin use suggests a possible myocardial infarction (MI), requiring immediate medical intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
A. Massaging the calves is incorrect. This action can dislodge a deep vein thrombus (DVT), increasing the risk of a pulmonary embolism.
B. Applying elastic compression stockings is correct. These help promote venous return, reducing the risk of blood stasis and clot formation.
C. Performing passive range of motion exercises is correct. These exercises prevent venous stasis, which is a major risk factor for DVT and PE.
D. Assessing legs for redness is correct. Redness, swelling, and warmth can indicate DVT formation, allowing for early intervention before it leads to PE.
E. Placing pillows under the client's knees is incorrect. This can impair circulation and increase the risk of clot formation by promoting venous stasis.
Correct Answer is C
Explanation
A. A complete occlusion of the coronary artery is characteristic of an ST-segment elevation myocardial infarction (STEMI), not an NSTEMI.
B. Chest pain that resolves with rest is more indicative of stable angina rather than NSTEMI.
C. An NSTEMI occurs due to a partial occlusion of a coronary artery, leading to myocardial ischemia and damage without ST-segment elevation on an ECG.
D. Chest pain at rest can be seen in both unstable angina and NSTEMI, but it is not the defining feature of NSTEMI.
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