After administering sublingual nitroglycerin to a client with chest pain, it is most important for the nurse to assess:
Blood pressure.
Blood glucose levels.
Body temperature.
Respiratory rate.
The Correct Answer is A
Choice A reason: This is correct. Blood pressure is the most important vital sign to monitor after giving sublingual nitroglycerin to a client with chest pain. Nitroglycerin is a medication that dilates the blood vessels and lowers the blood pressure. This can relieve the chest pain caused by angina, which is a condition where the heart muscle does not get enough oxygen due to narrowed or blocked arteries. However, if the blood pressure drops too low, the client may experience dizziness, fainting, or shock. Therefore, the nurse should check the blood pressure before and after giving nitroglycerin and report any significant changes to the doctor.
Choice B reason: This is incorrect. Blood glucose levels are not directly affected by sublingual nitroglycerin. However, some clients with chest pain may also have diabetes, which is a risk factor for heart disease. Diabetes is a condition where the body cannot regulate the amount of sugar in the blood. High or low blood sugar levels can cause symptoms such as thirst, hunger, fatigue, blurred vision, or confusion. Therefore, the nurse should check the blood glucose levels of clients with diabetes and follow the doctor's orders for managing their blood sugar.
Choice C reason: This is incorrect. Body temperature is not directly affected by sublingual nitroglycerin. However, some clients with chest pain may also have a fever, which is a sign of infection or inflammation. Fever is a condition where the body's temperature rises above the normal range. Fever can cause symptoms such as sweating, chills, headache, or muscle ache. Therefore, the nurse should check the body temperature of clients with fever and follow the doctor's orders for treating their infection or inflammation.
Choice D reason: This is incorrect. Respiratory rate is not directly affected by sublingual nitroglycerin. However, some clients with chest pain may also have difficulty breathing, which is a sign of heart failure or lung disease. Difficulty breathing is a condition where the client cannot get enough air into or out of the lungs. Difficulty breathing can cause symptoms such as coughing, wheezing, or gasping. Therefore, the nurse should check the respiratory rate of clients with difficulty breathing and follow the doctor's orders for improving their oxygenation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is incorrect. Reviewing the patient’s previous blood glucose levels may not be helpful in determining the correct dose of insulin, as the blood glucose level can fluctuate depending on various factors, such as food intake, activity, stress, and illness. The previous blood glucose levels may not reflect the current insulin needs of the patient¹.
Choice B reason: This is incorrect. No review is not an option before administering insulin, as insulin is a highalert medication that can cause serious harm if given incorrectly. The nurse should always check the patient’s blood glucose level, the insulin order, the insulin type, the insulin dose, the insulin expiration date, and the insulin injection site before giving insulin.
Choice C reason: This is correct. Reviewing the Regular insulin sliding scale for administration in the patient’s electronic medical record is the best action to determine the correct dose of insulin. A sliding scale is a chart of insulin dosages based on blood glucose level and mealtime. It is used to adjust the insulin dose according to the patient’s blood glucose level and insulin sensitivity. The nurse should follow the sliding scale protocol and verify the insulin dose with another nurse before administering it.
Choice D reason: This is incorrect. Reviewing the patient’s previous insulin administration doses may not be helpful in determining the correct dose of insulin, as the insulin dose may vary depending on the patient’s blood glucose level and insulin sensitivity. The previous insulin doses may not reflect the current insulin needs of the patient¹.
Correct Answer is D
Explanation
Choice A reason: This is incorrect. Aspirin can be used to relieve headache, but that is not its main function in this context. Aspirin is prescribed to patients who have had a heart attack to reduce the risk of another one.
Choice B reason: This is incorrect. Aspirin can be used to reduce fever, but that is not its main function in this context. Aspirin is prescribed to patients who have had a heart attack to reduce the risk of another one.
Choice C reason: This is incorrect. Aspirin does not act as an antiviral. It has no effect on viral infections. Aspirin is prescribed to patients who have had a heart attack to reduce the risk of another one.
Choice D reason: This is correct. Aspirin prevents further clot formation by inhibiting the activity of platelets, which are blood cells that help form clots. Clots can block the blood flow to the heart and cause a heart attack. Aspirin reduces the chance of this happening by making the blood less sticky.
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