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 A
Explanation
Choice A reason: This is correct. Constipation is a common side effect of aluminum hydroxide, as it reduces the motility of the gastrointestinal tract. The nurse should advise the client to report this symptom and to increase their fluid and fiber intake to prevent it.
Choice B reason: This is incorrect. Flatulence is not a common side effect of aluminum hydroxide. It may be caused by other factors, such as diet, swallowing air, or bacterial overgrowth in the intestines.
Choice C reason: This is incorrect. Headache is not a common side effect of aluminum hydroxide. It may be caused by other factors, such as stress, dehydration, or caffeine withdrawal.
Choice D reason: This is incorrect. Palpitations are not a common side effect of aluminum hydroxide. They may be caused by other factors, such as anxiety, heart problems, or medication interactions.
Correct Answer is A
Explanation
Choice A reason: This is correct. Excedrin contains a combination of aspirin, acetaminophen, and caffeine. Aspirin is a nonsteroidal anti-inflammatory drug (NSAID) that reduces pain, inflammation, and swelling. Acetaminophen is a pain reliever and a fever reducer. Caffeine is a central nervous system stimulant that enhances the pain-relieving function of aspirin and acetaminophen.
Choice B reason: This is incorrect. Ibuprofen and naproxen are both NSAIDs, but they are not the same as aspirin. They have different chemical structures and may have different effects and side effects. Caffeine is not an ingredient in ibuprofen or naproxen products.
Choice C reason: This is incorrect. Loratadine is an antihistamine that is used to treat allergies, not headaches. It does not have any pain-relieving or anti-inflammatory properties. Caffeine is not an ingredient in loratadine products.
Choice D reason: This is incorrect. Naproxen is an NSAID, but it is not the same as aspirin. It has a different chemical structure and may have different effects and side effects. Loratadine is an antihistamine that is used to treat allergies, not headaches. It does not have any pain-relieving or anti-inflammatory properties. Caffeine is not an ingredient in acetaminophen, naproxen, or loratadine products.
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