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. Calcium channel blocker: Calcium channel blockers (e.g., amlodipine, diltiazem) do not commonly cause a dry cough. They primarily work by relaxing blood vessels and reducing heart workload.
B. Angiotensin II receptor blocker: ARBs (e.g., losartan, valsartan) do not typically cause a persistent cough. They are often prescribed instead of ACE inhibitors for patients who experience this side effect.
C. Angiotensin-converting enzyme (ACE) inhibitors: ACE inhibitors (e.g., lisinopril, enalapril) can cause a persistent dry cough due to the accumulation of bradykinin, a substance that can irritate the airways.
D. Beta-blockers: Beta-blockers (e.g., metoprolol, propranolol) are not commonly associated with a dry cough. They mainly affect heart rate and blood pressure but can cause bronchospasms in some patients.
Correct Answer is D
Explanation
- Sensory perception: Slightly limited (score of 3)
- Moisture: Rarely moist (score of 4)
- Activity: Walks occasionally (score of 3)
- Mobility: Slightly limited (score of 3)
- Nutrition: Excellent intake (score of 4)
- Friction and shear: No apparent problem (score of 3)
Adding these scores together: 3 + 4 + 3 + 3 + 4 + 3 = 20
Therefore, the nurse should document a score of 20 for this patient.
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