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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Myocardial contractility × myocardial blood flow: While myocardial contractility and blood flow affect cardiac output, they are not part of the formula for calculating it.
B. Ventricular filling time/diastolic filling time: This ratio does not determine cardiac output. While diastolic filling time affects stroke volume, it is not the standard formula for cardiac output.
C. Stroke volume × heart rate: Cardiac Output (CO) = Stroke Volume (SV) × Heart Rate (HR). Stroke volume is the amount of blood pumped per beat, and heart rate is the number of beats per minute. Multiplying these values gives the total volume of blood pumped per minute, making this the correct formula.
D. Preload/afterload: Preload and afterload influence cardiac function but are not used to directly calculate cardiac output.
Correct Answer is D
Explanation
A. Aortic and Mitral: The mitral valve is associated with the S1 sound, not S2. S2 occurs when the semilunar valves (aortic and pulmonic) close.
B. Mitral and Pulmonic: The mitral valve closure is heard in S1, while the pulmonic valve closure is part of S2. However, the mitral valve is not involved in S2.
C. Mitral and Tricuspid: The mitral and tricuspid valves close during S1, not S2. These valves are atrioventricular (AV) valves, not semilunar valves.
D. Aortic and Pulmonic: The second heart sound (S2) is produced by the closure of the aortic and pulmonic valves at the beginning of diastole. This marks the end of systole.
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