Exhibits
Which 2 statements from the client should the nurse recognize as a need for further education?
I will keep my nitroglycerin tablets with me all the time.
I will chew my nitroglycerin tabs as soon as pain begins.
I will call 911 if there is no improvement in my chest pain after taking nitroglycerin.
I will take the nitroglycerin 1 or 2 more times 10 minutes apart if pain does not get better.
I will wait 5 minutes after taking my nitroglycerin to see if the pain improves.
I will lie down or sit if I start to feel any chest discomfort.
I will wear a medication alert bracelet to indicate my history of heart problems.
Correct Answer : B,D
A. I will keep my nitroglycerin tablets with me all the time: This is appropriate and essential for clients at risk for angina. Having immediate access to nitroglycerin ensures timely administration at the onset of chest pain.
B. I will chew my nitroglycerin tabs as soon as pain begins: Nitroglycerin tablets should never be chewed or swallowed. They are sublingual and must dissolve under the tongue to be rapidly absorbed through the mucosa for immediate effect. Chewing the tablet reduces effectiveness and delays pain relief.
C. I will call 911 if there is no improvement in my chest pain after taking nitroglycerin: Emergency services should be contacted if pain persists after one dose. This statement reflects proper understanding of when to seek urgent care during a possible cardiac event.
D. I will take the nitroglycerin 1 or 2 more times 10 minutes apart if pain does not get better: Sublingual nitroglycerin should be taken every 5 minutes, not 10 minutes, for a maximum of 3 doses. Delaying additional doses may prolong ischemia and increase the risk of myocardial damage during an acute episode.
E. I will wait 5 minutes after taking my nitroglycerin to see if the pain improves: Evaluating pain relief after 5 minutes is consistent with recommended protocols. If pain persists, a second dose may be taken, followed by a third dose 5 minutes later if needed.
F. I will lie down or sit if I start to feel any chest discomfort: This helps reduce myocardial oxygen demand and prevent injury from dizziness due to nitroglycerin-induced hypotension. It’s a safe and appropriate action.
G. I will wear a medication alert bracelet to indicate my history of heart problems: Medical ID jewelry is recommended for clients with cardiovascular history to inform emergency responders about potential cardiac conditions and medications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Headache with sudden onset: While a sudden headache can be concerning and suggest a neurologic issue, it is not the most immediate sign of hemodynamic instability in the context of atrial fibrillation with hypotension. The priority is assessing cerebral perfusion.
B. Flat jugular vein distention (JVD) at 45 degrees: Flat JVD may reflect low central venous pressure, which is consistent with hypotension but is not as critical as changes in neurologic status. It is a supportive finding rather than a primary indicator to report.
C. Abnormal level of consciousness: Altered mental status indicates reduced cerebral perfusion due to a dangerously low cardiac output from rapid atrial fibrillation and hypotension. This is a critical, life-threatening sign that demands immediate medical intervention to restore adequate perfusion.
D. Nausea with vomiting: These symptoms can occur with hypotension or sympathetic stimulation but are nonspecific and less urgent compared to neurologic compromise. They do not require the same immediate action as a change in consciousness.
Correct Answer is D
Explanation
A. Accelerated junctional rhythm: An accelerated junctional rhythm originates in the AV junction (40-100 bpm), typically has absent, inverted, or hidden P waves (before, during, or after QRS), and a regular rhythm. This strip has clear, upright P waves, an irregular rhythm, and a lengthening PR interval.
B. Premature atrial contractions (PAC): PACs are single ectopic beats that occur earlier than expected, originating in the atria. While they involve P waves, they don't show a pattern of progressively lengthening PR intervals or dropped beats in the characteristic Wenckebach pattern.
C. Atrial fibrillation (A-fib): Atrial fibrillation is characterized by irregularly irregular R-R intervals, chaotic atrial activity with no discernible P waves, and a variable ventricular rate. This strip clearly shows discernible P waves.
D. Wenckebach, Mobitz Type I atrioventricular (AV) block: This rhythm is defined by a progressive lengthening of the PR interval until a QRS complex is dropped. The cycle then repeats. This is what is observed in the ECG strip.
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