A nurse on the telemetry(cardiac unit) is caring for a client who has unstable angina and is reporting chest pain with a severity of 6 on a 0-10 pain scale. The nurse administers 1 nitroglycerin (sublingual). 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?

Initiate a peripheral IV

Administer another nitroglycerin tablet

Obtain an ECG/EKG

Call the Rapid Response Team

Answer and Explanation

The Correct Answer is C

A. Initiate a peripheral IV: While an IV line is useful for medication administration, the patient’s pain has significantly improved with nitroglycerin. An IV may be necessary later, but it is not the next step in this scenario.

B. Administer another nitroglycerin tablet: Nitroglycerin can be repeated every 5 minutes up to 3 doses if chest pain persists or does not decrease significantly. Since the pain has improved (from 6 to 2), additional nitroglycerin is unnecessary.

C. Obtain an ECG/EKG: Even though the pain improved, unstable angina can progress to myocardial infarction. An ECG helps evaluate for ischemic changes and ensures the pain is truly resolving.

D. Call the Rapid Response Team (RRT): RRT should be called for worsening chest pain, unresponsiveness, or hemodynamic instability. Since the pain has improved, calling RRT is unnecessary.

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 ["C","D"]

Explanation

A. Nonproductive cough: Diphenhydramine is an antihistamine, not a cough suppressant. It does not cause a nonproductive cough as a side effect.

B. Drowsiness: First-generation antihistamines (like diphenhydramine) cause CNS depression, leading to drowsiness.

C. Urinary retention: Diphenhydramine has anticholinergic effects, which can lead to urinary retention, especially in older adults or those with prostate issues.

D. Dry mouth: Diphenhydramine blocks muscarinic receptors, reducing saliva production and causing dry mouth.

E. Skin rash: Skin rash is not a common adverse effect of diphenhydramine but can be a sign of an allergic reaction.

A. Pleural effusion B. Hypoxemia C. Dysphagia D. Apnea

Correct Answer is B

Explanation

A. Pleural effusion: A pleural effusion is the accumulation of fluid in the pleural space and is not directly related to atelectasis. Atelectasis is alveolar collapse and does not cause fluid buildup.

B. Hypoxemia: Atelectasis impairs gas exchange, leading to decreased oxygen levels (hypoxemia) due to collapsed alveoli. This is a hallmark finding.

C. Dysphagia: Dysphagia (difficulty swallowing) is not a direct symptom of atelectasis. It may be seen in stroke or esophageal disorders.

D. Apnea: Apnea (cessation of breathing) is not a typical sign of atelectasis. Atelectasis causes shallow breathing, dyspnea, and hypoxia rather than complete cessation.

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 nurse is teaching a client who has a new prescription for diphenhydramine for allergic rhinitis. The nurse should instruct the client to monitor for which of the following manifestations as an adverse effect of this medication? (Select all that apply.)

Correct Answer is ["C","D"]

Explanation

A nurse is caring for a client 1 day postoperative who has developed atelectasis. Which of the following manifestations is an expected finding for this condition?

Correct Answer is B

Explanation

A patient who has been taking antihypertensive drugs for a few months states that a new, persistent dry cough is very bothersome. The nurse knows that this cough is an adverse effect of which class of antihypertensive drugs?

The nurse is caring for a patient who has experienced a laparoscopic appendectomy. For which type of healing will the nurse focus the care plan?

A nurse is working in the intensive care unit and must obtain core temperatures on patients. Which sites can be used to obtain a core temperature? (Select all that apply.)

Which patient scenario of a surgical patient in pain is most indicative of critical thinking?

The nurse is caring for a patient who has a wound drain with a collection device. The nurse notices that the collection device has a sudden decrease in drainage.

A nurse is caring for a patient with a wound. Which assessment data will be most relevant with regard to wound healing?

A patient diagnosed with chronic obstructive pulmonary disease (COPD) asks the nurse why clubbing occurs. Which response by the nurse is the most therapeutic?