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 A
Explanation
A. Delivering a continuous flow of air pressure to keep the airway open is correct. CPAP (Continuous Positive Airway Pressure) prevents airway collapse during sleep, allowing for uninterrupted breathing and oxygenation.
B. Reducing daytime sleepiness is a benefit of CPAP use, but it is not its primary purpose—it is a secondary effect of improved oxygenation and sleep continuity.
C. Improving sleep quality also occurs with CPAP therapy, but this is an outcome rather than the primary purpose.
D. Promoting weight loss is not the function of CPAP therapy, though weight loss can help reduce OSA severity.
Correct Answer is C
Explanation
A. Drawing a basic metabolic panel (BMP) is important for monitoring electrolyte imbalances, especially potassium in clients on diuretics, but it is not the priority intervention.
B. Obtaining a health history is necessary, but assessing the client’s current status takes priority in an acute setting.
C. Auscultating the lung and heart sounds is correct. In heart failure, pulmonary congestion and fluid overload can quickly lead to respiratory distress. The nurse should immediately assess for crackles, wheezing, or signs of pulmonary edema, as well as abnormal heart sounds that may indicate worsening heart failure.
D. Assessing pulse and temperature is routine, but assessing lung and heart sounds directly evaluates for acute decompensation and should be prioritized.
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