A nurse is reinforcing discharge teaching about sublingual nitroglycerin with a client who has angina. Which of the following statements indicates an understanding of the instructions?
"I am going to take the medication with food.”
"I understand that the medication can slow my heart rate.”
"I should feel the effects of the medication within 5 minutes.”
"I will take the medication every 10 minutes until the pain goes away.”
The Correct Answer is C
Choice A rationale:
The statement about taking the medication with food is incorrect. Nitroglycerin sublingual tablets should not be taken with food. They work much faster when absorbed through the lining of the mouth.
Choice B rationale:
The statement that the medication can slow the heart rate is incorrect. Nitroglycerin does not slow the heart rate. In fact, it can cause a reflex tachycardia, where the heart rate increases.
Choice C rationale:
The statement that the effects of the medication should be felt within 5 minutes is correct. This indicates an understanding of the instructions.
Choice D rationale:
Taking the medication every 10 minutes until the pain goes away is incorrect. Nitroglycerin sublingual tablets usually give relief in 1 to 5 minutes. However, if the pain is not relieved, a second tablet can be taken 5 minutes after the first tablet. If the pain continues for another 5 minutes, a third tablet may be used. Taking the medication every 10 minutes could lead to an overdose.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
A negative mammogram is not a requirement of the iPLEDGE program. Mammograms are used to screen for breast cancer and are not related to isotretinoin therapy.
Choice B rationale:
Regular Papanicolaou tests, which screen for cervical cancer, are not a requirement of the iPLEDGE program. These tests are not related to isotretinoin therapy.
Choice C rationale:
There is no requirement for clients to begin a daily supplement of vitamin A prior to initiating therapy. In fact, taking additional vitamin A while on isotretinoin can increase the risk of vitamin A toxicity.
Choice D rationale:
Sexually active female clients must use two forms of birth control during treatment. This is because isotretinoin can cause severe birth defects.
Correct Answer is B
Explanation
Choice A rationale:
Injecting the medication at least 5 cm (2 in) from the umbilicus is not a standard guideline for IM injections. The site of injection depends on factors such as the volume of medication and patient’s age and muscle mass.
Choice B rationale:
Using the Z-track technique to administer the medication is correct. This technique helps to seal the medication in muscle tissue, reducing leakage into subcutaneous tissue.
Choice C rationale:
Giving the medication without aspirating prior to injection is not recommended. Aspiration ensures that the needle is not in a blood vessel before injecting.
Choice D rationale:
Administering the medication with a 27-gauge '/,-inch needle may not be appropriate for an IM injection, especially for adults. A longer and larger gauge needle is typically used for IM injections.
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