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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: "I am not ready to eat lunch yet." is not a concerning statement for the patient who has completed their Albuterol nebulizer treatment. Albuterol is a medication that relaxes the muscles in the airways and increases the airflow to the lungs, which can improve the breathing and reduce the wheezing in patients with asthma¹. Albuterol does not affect the appetite or the digestion directly, but it may cause some side effects such as nausea, vomiting, or dry mouth, which may reduce the desire to eat. The nurse should respect the patient's preference and offer them food later when they are ready.
Choice B reason: "It feels like my heart is racing." is a concerning statement for the patient who has completed their Albuterol nebulizer treatment. Albuterol is a medication that relaxes the muscles in the airways and increases the airflow to the lungs, but it also stimulates the beta receptors in the heart, which can increase the heart rate and the blood pressure¹. This can cause side effects such as palpitations, chest pain, or arrhythmias, especially in patients with underlying heart conditions or those who take other medications that affect the heart. The nurse should monitor the patient's vital signs, report the finding to the prescriber, and prepare to administer interventions such as betablockers or calcium channel blockers to lower the heart rate and prevent complications.
Choice C reason: "It is easier to breathe now." is not a concerning statement for the patient who has completed their Albuterol nebulizer treatment. Albuterol is a medication that relaxes the muscles in the airways and increases the airflow to the lungs, which can improve the breathing and reduce the wheezing in patients with asthma¹. This is the expected and desired outcome of the Albuterol nebulizer treatment, which indicates that the medication is effective and the patient is responding well. The nurse should document the patient's response and continue to assess the patient's respiratory status and oxygen saturation.
Choice D reason: "I can breathe better now." is not a concerning statement for the patient who has completed their Albuterol nebulizer treatment. Albuterol is a medication that relaxes the muscles in the airways and increases the airflow to the lungs, which can improve the breathing and reduce the wheezing in patients with asthma¹. This is the expected and desired outcome of the Albuterol nebulizer treatment, which indicates that the medication is effective and the patient is responding well. The nurse should document the patient's response and continue to assess the patient's respiratory status and oxygen saturation.
Correct Answer is A
Explanation
Choice A reason: This is correct. Hypertension is a contraindication for taking pseudoephedrine. Pseudoephedrine is a decongestant that shrinks the blood vessels in the nasal passages and relieves congestion. However, it can also increase the blood pressure and the heart rate, which can worsen hypertension and increase the risk of stroke, heart attack, or kidney damage. The nurse should advise the client to avoid pseudoephedrine and use other methods to relieve sinus congestion, such as saline nasal spray, steam inhalation, or humidifier.
Choice B reason: This is incorrect. Diverticulitis is not a contraindication for taking pseudoephedrine. Diverticulitis is a condition where small pouches in the colon become inflamed and infected. It can cause symptoms such as abdominal pain, fever, nausea, or constipation. Pseudoephedrine does not affect the colon or the inflammation directly, but it can cause dehydration, which can worsen constipation and diverticulitis. The nurse should advise the client to drink plenty of fluids and eat a highfiber diet to prevent constipation and diverticulitis.
Choice C reason: This is incorrect. Migraines are not a contraindication for taking pseudoephedrine. Migraines are severe headaches that are often accompanied by nausea, vomiting, or sensitivity to light and sound. They can be triggered by various factors, such as stress, hormones, or food. Pseudoephedrine does not cause migraines directly, but it can interact with some migraine medications, such as triptans, which are used to treat acute migraine attacks. The combination of pseudoephedrine and triptans can increase the blood pressure and the risk of serotonin syndrome, a serious condition that causes agitation, confusion, tremors, or seizures. The nurse should advise the client to check with their doctor before taking pseudoephedrine and triptans together.
Choice D reason: This is incorrect. Eczema is not a contraindication for taking pseudoephedrine. Eczema is a skin condition that causes dry, itchy, and inflamed skin. It can be caused by various factors, such as allergies, irritants, or genetics. Pseudoephedrine does not affect the skin or the inflammation directly, but it can cause dryness of the mucous membranes, such as the mouth, nose, or eyes. The nurse should advise the client to use a moisturizer, a lip balm, and artificial tears to prevent dryness and irritation of the skin and the mucous membranes.
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