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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Fluticasone is a corticosteroid used to manage asthma and COPD symptoms and does not typically require clarification.
Choice B rationale
Furosemide is a diuretic used to manage fluid overload in heart failure and does not require clarification.
Choice C rationale
Carvedilol is a non-selective beta-blocker that can exacerbate asthma symptoms and bronchospasm. It should be avoided in clients with a history of asthma.
Choice D rationale
Isosorbide dinitrate is a nitrate used to manage angina and heart failure and does not require clarification.
Correct Answer is A
Explanation
Choice A rationale
Using the inhaler before engaging in physical activity helps to prevent exercise-induced bronchospasm, which is common in patients with COPD.
Choice B rationale
Skipping doses if symptoms improve is not recommended as it can lead to suboptimal control of COPD and potential exacerbations.
Choice C rationale
Using the inhaler only when experiencing severe symptoms is not effective in managing COPD. Regular use as prescribed helps maintain lung function and prevent exacerbations.
Choice D rationale
Doubling the dose if symptoms do not improve immediately is not safe and can lead to adverse effects. Patients should follow the prescribed dosage and consult their healthcare provider if symptoms persist.
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