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 B
Explanation
Choice A rationale:
Asking the client to demonstrate dose delivery can be part of patient education and helps ensure that the client understands how to use the PCA device. This action does not require intervention.
Choice B rationale:
The nurse administering a PCA dose for the client requires intervention. PCA stands for “Patient-Controlled Analgesia,” meaning that only the patient should administer doses to themselves. This prevents overdosing and ensures that pain medication is administered according to the patient’s needs.
Choice C rationale:
Reassuring the client that the PCA device will not cause an overdose is appropriate because PCA devices are designed with safety measures to prevent overdosing.
Choice D rationale:
Monitoring for oversedation is an important part of care for a client using a PCA device. This action does not require intervention.
Correct Answer is D
Explanation
Choice A rationale:
A Positive Chvostek’s sign is a clinical finding associated with hypocalcemia, or low levels of calcium in the blood. It’s not directly related to glyburide usage or symptoms of anxiety and profuse sweating.
Choice B rationale:
Pitting pedal edema occurs when excess fluid builds up in the body, causing swelling. It’s not directly related to glyburide usage or symptoms of anxiety and profuse sweating.
Choice C rationale:
Decreased deep-tendon reflexes or hyporeflexia happens when your skeletal muscles have a decreased or absent reflex response. It’s not directly related to glyburide usage or symptoms of anxiety and profuse sweating.
Choice D rationale:
Decreased blood glucose level or hypoglycemia occurs when your blood sugar (glucose) level falls too low. Glyburide is an oral diabetes medicine that helps control blood sugar levels. Anxiety and profuse sweating are symptoms of low blood sugar.
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