A nurse on a telemetry unit is caring for a client who has unstable angina and is reporting chest pain with a severity of 6 on a 0 to 10 scale.The nurse administers 1 sublingual nitroglycerin tablet.
After 5 minutes, the client states that his chest pain is now a severity of 2. Which of the following actions should the nurse take?

Obtain an ECG.

Call the Rapid Response Team.

Administer another nitroglycerin tablet.

Initiate a peripheral IV.

Answer and Explanation

The Correct Answer is C

Choice C rationale

Administering another nitroglycerin tablet is appropriate if the client's chest pain has not been fully relieved after the initial dose. Nitroglycerin helps to dilate blood vessels, improving blood flow to the heart and relieving angina. A second dose can be given if the pain persists, following the protocol for managing chest pain.

Choice A rationale

Obtaining an ECG is important for diagnosing and monitoring cardiac conditions; however, in this immediate context, further pain relief takes precedence. After ensuring pain relief, an ECG can be performed to assess the client's cardiac status.

Choice B rationale

Calling the Rapid Response Team is unnecessary if the client’s chest pain severity has already decreased. The priority should be to continue managing the chest pain with additional nitroglycerin if needed and monitoring the client's response.

Choice D rationale

Initiating a peripheral IV might be required for administering medications or fluids, but it is not the immediate action needed in this scenario. The priority is to provide additional pain relief with nitroglycerin.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale

Nasal congestion is not a symptom associated with acute cystitis. Acute cystitis primarily affects the urinary system.

Choice B rationale

Dysuria, which means painful or difficult urination, is a common symptom of acute cystitis, as it involves inflammation of the bladder and urethra.

Choice C rationale

Shortness of breath is not a typical symptom of acute cystitis. Acute cystitis symptoms are localized to the urinary tract.

Choice D rationale

Joint pain is not associated with acute cystitis. The symptoms of acute cystitis are related to the urinary system.

A. Hypokalemia. B. Hypovolemia. C. Fluid overload. D. Hypernatremia.

Correct Answer is C

Explanation

Choice A rationale

Hypokalemia is a potential concern with diuretic therapy, but not with hypertonic saline solution (3% NaCl) administration for hyponatremia.

Choice B rationale

Hypovolemia is less likely to occur with hypertonic saline infusion. The main concern is overcorrection leading to fluid overload.

Choice C rationale

Fluid overload is a significant risk when administering hypertonic saline (3% NaCl). Nurses should closely monitor for signs of fluid overload, such as edema, crackles in the lungs, and increased blood pressure.

Choice D rationale

Hypernatremia is a possible complication of hypertonic saline administration, but it is not as immediate a concern as fluid overload. Monitoring for fluid overload should take precedence.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 24-year-old female client comes to the ambulatory care center in moderate distress with a probable diagnosis of acute cystitis.Which symptom should the nurse expect the client to report during the assessment?

Correct Answer is B

Explanation

A patient is receiving 3% NaCl solution for correction of hyponatremia.For which of the following will the nurse assess?

Correct Answer is C

Explanation

A client is admitted to the emergency room with chest pain and a suspected diagnosis of acute myocardial infarction (MI). Which test would the nurse expect the physician to order to make a definitive diagnosis of MI?

A client is admitted to the emergency room with renal colic due to renal lithiasis (stones). What is the nurse's highest priority in managing care for this client?

A nurse is caring for a client who is 5 hours postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour.Which of the following actions should the nurse take first?

A nurse is caring for a client who has diabetic ketoacidosis and hypoxia.Which of the following interventions is most critical to perform immediately?

A nurse is caring for a client who has heart failure and a new prescription for furosemide.Which of the following laboratory values should the nurse review before administering furosemide?

Which outcome is appropriate for the client problem of "ineffective gas exchange" for the client diagnosed with chronic obstructive pulmonary disease (COPD)?

A nurse is evaluating a client who had a left-sided cardiac catheterization with an upper extremity insertion site.Which of the following actions should the nurse take?

A nurse is preparing to administer digoxin 1.5 mg PO to a client. The amount available is digoxin 0.5 mg/tablet. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)