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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Correct Answer is C

Explanation

A. Ascending edema:

Ascending edema, also known as dependent edema, is typically associated with right-sided heart failure rather than left-sided heart failure. In right-sided heart failure, the heart's ability to pump blood to the lungs for oxygenation is compromised, leading to fluid backup in the systemic circulation. This fluid accumulates in the dependent areas of the body, such as the lower extremities (legs and ankles), causing swelling that can ascend upwards if left untreated. However, ascending edema is not a characteristic finding in left-sided heart failure, where pulmonary congestion and orthopnea are more common manifestations.

B. The client has no desire to eat:

While decreased appetite can occur in heart failure due to various factors such as fluid retention, abdominal bloating, or medication side effects, it is not a specific hallmark of left-sided heart failure. Symptoms such as fatigue, dyspnea (shortness of breath), orthopnea (difficulty breathing while lying flat), and paroxysmal nocturnal dyspnea (PND) are more commonly associated with left-sided heart failure. These symptoms result from the impaired function of the left ventricle, leading to pulmonary congestion and inadequate oxygenation.

C. The client sleeps on three pillows at night:

This choice is the correct answer. Sleeping on three pillows at night is a classic manifestation of orthopnea, a condition commonly seen in left-sided heart failure. Orthopnea refers to difficulty breathing while lying flat, which is alleviated by elevating the head and upper body with multiple pillows or sleeping in a semi-upright position. Orthopnea occurs due to the redistribution of fluid from the legs and lower body to the lungs when lying down, resulting in pulmonary congestion and respiratory distress.

D. The client has a five-pound weight gain:

Weight gain is a common symptom of fluid retention in heart failure; however, a specific weight gain of five pounds alone may not be indicative of left-sided heart failure without considering other clinical signs and symptoms. In heart failure, weight gain is often associated with fluid overload, which can lead to edema, dyspnea, orthopnea, and other signs of congestion. It's important to assess the client comprehensively for fluid status, including evaluating for edema, respiratory symptoms, and changes in weight over time, to determine the underlying cause of weight gain.

A. The nurse stays with the client for 15 minutes after beginning the transfusion. B. The nurse primes the blood tubing with lactated ringers. C. The nurse starts the infusion at a slow rate for the first 15 minutes. D. The nurse witnesses the client sign the consent form for the blood transfusion.

Correct Answer is B

Explanation

A. The nurse stays with the client for 15 minutes after beginning the transfusion:

This action is appropriate as it ensures the nurse monitors the client closely for any immediate adverse reactions during the initial phase of the transfusion.

B. The nurse primes the blood tubing with lactated Ringer's solution:

This action is incorrect and potentially dangerous. Blood tubing should be primed with normal saline (0.9% sodium chloride) solution, not lactated Ringer's solution, to prevent potential adverse reactions or hemolysis of the blood products.

C. The nurse starts the infusion at a slow rate for the first 15 minutes:

This action is appropriate as it allows for the initial assessment of the client's tolerance to the transfusion and reduces the risk of adverse reactions.

D. The nurse witnesses the client sign the consent form for the blood transfusion:

This action is appropriate and ensures that the client has provided informed consent for the procedure.

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Naxlex Comprehensive Predictor Exams

The nurse is assessing a client with left-sided heart failure. What would the nurse expect to find?

Correct Answer is C

Explanation

A charge nurse is precepting a newly licensed nurse who is to administer a transfusion of packed red blood cells (PRBC) to a client who has anemia. Which of the following actions by the new nurse should cause the charge nurse to intervene in this client's care immediately?

Correct Answer is B

Explanation

The nurse is caring for a client newly diagnosed with hypertension. Which statement by the client indicates the need for further teaching?

A client is scheduled for a transthoracic echocardiography (TTE). What should the nurse teach the client in anticipation of this diagnostic procedure?

The mother of a teenage boy with sickle cell anemia asks the nurse why her son has such horrible pain during a sickle cell crisis. Which of the following is the best response by the nurse?

A patient admitted to the unit displays the following cardiac rhythm on telemetry. What is the estimated heart rate?

A nurse is admitting a client who has acute heart failure following myocardial infarction (MI). The nurse recognizes that which of the following prescriptions by the provider requires clarification?

A nurse receives a unit of packed RBCs from a blood bank and notes that the time is 1130. The nurse should begin the infusion at which of the following times?

A client with heart failure is placed on a low-sodium diet. Which statement by the client indicates that the nurse's nutritional teaching plan has been effective?