A nurse teaches a client with angina pectoris that he or she needs to take up to three sublingual nitroglycerin tablets at 5-minute intervals and immediately notify the health care provider if chest pain doesn’t subside within 15 minutes. What symptoms may the client experience after taking the nitroglycerin?

Nausea, vomiting, depression, fatigue, and impotence.

Sedation, nausea, vomiting, constipation, and respiratory depression.

Headache, hypotension, dizziness, and flushing.

Flushing, dizziness, headache, and pedal edema.

Answer and Explanation

The Correct Answer is C

Choice A reason: Nausea and vomiting may occur with nitroglycerin, but depression, fatigue, and impotence are unrelated. Headache and hypotension are primary effects, making this incorrect, as it includes irrelevant symptoms compared to the nurse’s teaching on nitroglycerin’s expected side effects.

Choice B reason: Sedation, constipation, and respiratory depression are opioid effects, not nitroglycerin, which causes vasodilation. Dizziness and flushing are correct, making this incorrect, as it misattributes opioid side effects to nitroglycerin in the nurse’s education for angina management.

Choice C reason: Nitroglycerin causes headache, hypotension, dizziness, and flushing due to vasodilation, common side effects. This aligns with pharmacological education for angina, making it the correct set of symptoms the nurse would teach the client to expect after taking sublingual nitroglycerin.

Choice D reason: Pedal edema is not a nitroglycerin side effect, though flushing, dizziness, and headache are. Hypotension is more precise than edema, making this incorrect, as it includes an unrelated symptom compared to the accurate side effects in nitroglycerin teaching.

Choice E reason: Decreased cardiac output and peripheral edema are not nitroglycerin effects; it improves coronary flow. Flushing is correct, but hypotension is key, making this incorrect, as it misrepresents nitroglycerin’s pharmacological effects in the nurse’s teaching for angina relief.

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Correct Answer is A

Explanation

Choice A reason: Palpation of a thrill, a vibrating sensation, indicates blood flow and patency in an arteriovenous fistula. This aligns with hemodialysis access assessment, making it the correct finding the nurse would use to confirm the fistula is patent.

Choice B reason: A radial pulse in the wrist is normal but doesn’t confirm fistula patency, which requires a thrill. Palpation of a thrill is specific, making this incorrect, as it’s not a direct indicator of fistula function in hemodialysis preparation.

Choice C reason: Enlarged vessels may suggest fistula development but don’t confirm active flow. A thrill indicates patency, making this incorrect, as it’s less specific than the nurse’s assessment of a palpable thrill over the fistula site.

Choice D reason: Capillary refill less than 3 seconds assesses distal perfusion, not fistula patency. Palpation of a thrill is the standard, making this incorrect, as it’s unrelated to the nurse’s evaluation of the arteriovenous fistula for hemodialysis.

A. pH: 7.40, PaO2: 90 mm Hg, CO2: 39 mEq/L, HCO3: 23 mEq/L. B. pH: 7.32, PaO2: 85 mm Hg, CO2: 57 mEq/L, HCO3: 26 mEq/L. C. pH: 7.47, PaO2: 82 mm Hg, CO2: 30 mEq/L, HCO3: 31 mEq/L. D. pH: 7.30, PaO2: 95 mm Hg, CO2: 22 mEq/L, HCO3: 19 mEq/L.

Correct Answer is B

Explanation

Choice A reason: Normal ABG values (pH 7.40, CO2 39) don’t reflect COPD’s chronic hypercapnia and compensated acidosis. pH 7.32 with elevated CO2 is typical, making this incorrect, as it doesn’t match the nurse’s expected findings in a client with chronic obstructive pulmonary disease.

Choice B reason: In COPD, chronic CO2 retention (57 mEq/L) causes respiratory acidosis (pH 7.32) with compensatory HCO3 increase (26 mEq/L). Low PaO2 (85 mm Hg) reflects hypoxemia. This aligns with COPD pathophysiology, making it the correct ABG finding the nurse anticipates in this client.

Choice C reason: Alkalotic pH (7.47) and low CO2 (30 mEq/L) suggest hyperventilation, not COPD’s CO2 retention. Acidosis with high CO2 is expected, making this incorrect, as it contradicts the typical ABG profile in the nurse’s assessment of a COPD client.

Choice D reason: Low CO2 (22 mEq/L) and acidosis (pH 7.30) suggest metabolic acidosis, not COPD’s respiratory acidosis with hypercapnia. Elevated CO2 is typical, making this incorrect, as it doesn’t reflect the nurse’s expected ABG findings in chronic obstructive pulmonary disease.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing the patency of a client’s left arm arteriovenous fistula prior to initiating hemodialysis. Which finding indicates that the fistula is patent?

Correct Answer is A

Explanation

The nurse caring for a client with chronic obstructive pulmonary disease (COPD) anticipates which arterial blood gas (ABG) findings?

Correct Answer is B

Explanation

Which action will the nurse perform first to prevent harm for a client suspected to have fluid overload?

A client suspected of having a duodenal ulcer has undergone esophagogastroduodenoscopy. The nurse would place the highest priority on which item as part of the client’s care plan?

The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of headache and nausea and is extremely restless. Which is the priority nursing action?

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You are working on a busy unit and need to delegate tasks to the LPN and M

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