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 min, the client states that his chest pain is now a severity of 2. Which of the following actions should the nurse take?

Initiate a peripheral IV.

Administer another nitroglycerin tablet.

Call the Rapid Response Team.

Obtain an ECG.

Answer and Explanation

The Correct Answer is B

A. Initiate a peripheral IV:

Initiating a peripheral intravenous (IV) line may be necessary for clients with unstable angina to facilitate the administration of medications and fluids, especially if there is a need for further interventions or if the client's condition deteriorates. However, in this case, the client's chest pain has improved after receiving nitroglycerin, and there is no immediate indication for IV access based on the information provided.

B. Administer another nitroglycerin tablet:

Nitroglycerin is a vasodilator commonly used to relieve chest pain (angina) by dilating blood vessels and improving blood flow to the heart. The initial response of the client's chest pain severity decreasing from 6 to 2 after one sublingual nitroglycerin tablet indicates a positive response to the medication. However, it's important to assess the client's response further before administering additional doses of nitroglycerin, especially considering the potential for hypotension or other adverse effects.

C. Call the Rapid Response Team:

The Rapid Response Team (RRT) is typically called in situations where there is a concern for a critical event or deterioration of a client's condition that requires immediate intervention. In this scenario, the client's chest pain has improved after nitroglycerin administration, and there are no indications of an acute critical event at this time. Therefore, calling the RRT is not warranted based on the client's current status.

D. Obtain an ECG:

An ECG can be helpful to assess for potential ischemia or other cardiac abnormalities. However, it's not the most urgent action when the client is responding positively to nitroglycerin. It can be done while monitoring the client's response to the second dose.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Weigh yourself once a week:

This is an important part of heart failure management as weight gain can indicate fluid retention, a common symptom of heart failure. The nurse should instruct the client to weigh themselves at the same time of day, using the same scale, and wearing similar clothing each time. Any sudden weight gain should be reported to the healthcare provider promptly.

B. Drink 3 liters of fluid per day:

This option is not appropriate for most heart failure patients, especially those with fluid retention issues. Fluid intake should be monitored and restricted based on the individual's condition and healthcare provider's recommendations. Consuming too much fluid can exacerbate fluid retention and worsen heart failure symptoms.

C. Engage in exercise daily:

Exercise is generally recommended for heart failure patients, but the type, intensity, and frequency of exercise should be tailored to the individual's condition. The nurse should encourage the client to engage in regular physical activity as tolerated, following a structured exercise plan approved by their healthcare provider. Activities like walking, cycling, or water aerobics can be beneficial for heart health.

D. Restrict dietary potassium:

This option is not typically included in lifestyle modifications for heart failure unless the client has specific potassium-related issues or is taking medications that require potassium restriction. Potassium is an important electrolyte for heart function, and most heart failure patients are advised to consume a balanced diet with moderate potassium intake, unless otherwise directed by their healthcare provider.

A. 120 beats/minute B. 80 beats/minute C. 40 beats/minute D. Unable to calculate with the strip provided.

Correct Answer is B

Explanation

The RR interval is 7.5 big boxes, multiplied by 10 makes it 75, rounded off is 80 beats per minute.

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Naxlex Comprehensive Predictor Exams

The nurse is teaching a client about lifestyle modifications after a heart failure diagnosis. What will be included in the teaching?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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