A nurse is reinforcing teaching with a client who uses a nitroglycerine patch to treat angina. The client now has a new prescription for nitroglycerin sublingual tablets. Which of the following instructions should the nurse include?

Swallow the tablet whole with an 8 oz glass of water.

Store the medication in a pill box at the bedside.

Take the medication at the first indication of chest pain.

Remove the nitroglycerine patch before taking the sublingual tablet.

Answer and Explanation

The Correct Answer is C

(A) Swallow the tablet whole with an 8 oz glass of water.
Sublingual nitroglycerin tablets should not be swallowed. They need to be placed under the tongue where they can dissolve and be absorbed quickly to provide rapid relief from angina.

(B) Store the medication in a pill box at the bedside.
Nitroglycerin sublingual tablets should be stored in their original container and kept tightly closed to protect them from light and moisture. Storing them in a pill box at the bedside could lead to degradation of the medication.

(C) Take the medication at the first indication of chest pain.
This is the correct instruction. Nitroglycerin sublingual tablets should be taken at the first sign of chest pain to provide prompt relief. The rapid onset of action helps to alleviate angina symptoms quickly.

(D) Remove the nitroglycerine patch before taking the sublingual tablet.
It is not necessary to remove the nitroglycerin patch before taking a sublingual tablet. The two forms of nitroglycerin can be used together, as the patch provides a continuous dose while the sublingual tablet offers rapid relief of acute symptoms.

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Correct Answer is C

Explanation

A. Hypoglycemia: Hypoglycemia, or low blood sugar, is not typically associated with hypokalemia. Hypokalemia is a condition characterized by low levels of potassium in the blood. While both conditions can occur due to certain diseases or medication use, they are not directly related.

B. Hyperreflexia: Hyperreflexia, a condition characterized by overactive reflexes, is not a common symptom of hypokalemia. Hypokalemia primarily affects muscle function, leading to symptoms such as muscle weakness, cramps, and potentially cardiac dysrhythmias. It does not typically cause an overactive reflex response.

C. Cardiac dysrhythmias: This is correct. Hypokalemia can lead to cardiac dysrhythmias. Potassium plays a crucial role in maintaining normal electrical activity in the heart. When potassium levels are low, it can disrupt this electrical activity, leading to irregular heart rhythms.

D. Increased appetite: Increased appetite is not a typical symptom of hypokalemia. In fact, loss of appetite is more commonly associated with this condition. Severe hypokalemia can affect the functioning of the muscles in the digestive system, leading to symptoms such as bloating, constipation, and abdominal pain.

A. Glasgow coma scale result B. Intracranial pressure readings C. Medication during the next shift D. History of the injury

Correct Answer is D

Explanation

(A) Glasgow coma scale result:
The Glasgow Coma Scale (GCS) result is important and would be included in the "Assessment" segment of SBAR, as it provides current data on the client's level of consciousness and neurological status.

(B) Intracranial pressure readings:
Intracranial pressure (ICP) readings are crucial for monitoring the client's condition but would be more appropriately included in the "Assessment" or "Background" segments, as they provide ongoing data relevant to the client's current health status and trends.

(C) Medication during the next shift:
Medication information, especially about what needs to be administered during the next shift, would fall under the "Recommendation" segment. This is where the outgoing nurse would specify what needs to be done next for the client's care.

(D) History of the injury:
The history of the injury is part of the "Situation" segment in SBAR reporting. This includes a brief description of why the client is being reported on, providing context for their current condition. For a client with a traumatic brain injury, this would involve a summary of how the injury occurred, which sets the stage for understanding the client's current status and care needs.

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A nurse is reinforcing teaching with a client who uses a nitroglycerine patch to treat angina. The client now has a new prescription for nitroglycerin sublingual tablets. Which of the following instructions should the nurse include?

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Naxlex Comprehensive Predictor Exams

A nurse is reviewing the laboratory results of a client who is taking furosemide and notes the client's potassium level is 3.0 mEq/L. Which of the following physiological responses should the nurse expect related to the client's hypokalemia?

Correct Answer is C

Explanation

A nurse is giving change-of-shift report using the SBAR technique about a client who has a traumatic brain injury. When reporting information about the client, which of the following should the nurse include in the situation segment of SBAR?

Correct Answer is D

Explanation

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