How will the nurse administer a nitroglycerin sublingual tablet to the patient?
Have the patient swallow the tablet with a sip of water.
Crush the tablet and dissolve it in a teaspoon of water.
Place the tablet in the patient’s mouth next to the cheek.
Place the tablet under the patient’s tongue.
The Correct Answer is D
Choice A rationale:
Incorrect because swallowing the tablet with water would lead to slower absorption and a delayed onset of action. Nitroglycerin is rapidly absorbed through the oral mucosa, and swallowing it would route it through the digestive system, where it would be absorbed more slowly and less effectively.
Swallowing the tablet could also increase the risk of side effects, such as headache and flushing, due to the larger amount of the drug that would be absorbed systemically.
Choice B rationale:
Incorrect because crushing the tablet and dissolving it in water would also delay its absorption. This method would require the tablet to dissolve in the water before it could be absorbed through the oral mucosa, which would slow down the onset of action.
Crushing the tablet could also damage the medication and make it less effective.
Choice C rationale:
Incorrect because placing the tablet in the patient's mouth next to the cheek would not allow for optimal absorption. The oral mucosa under the tongue is more permeable than the cheek, so placing the tablet under the tongue allows for faster and more efficient absorption.
Placing the tablet in the cheek could also increase the risk of the patient accidentally swallowing it.
Choice D rationale:
Correct because placing the tablet under the patient's tongue allows for rapid absorption and a quick onset of action. The sublingual route is the preferred method of administration for nitroglycerin because it allows the medication to bypass the digestive system and be absorbed directly into the bloodstream.
This method also allows for the patient to easily remove the tablet if they experience any side effects.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Stage 2 pressure injuries are characterized by partial-thickness loss of skin layers involving the epidermis and/or dermis. They present as a red, blistered area, often with an intact or ruptured serum-filled blister. The wound bed is typically moist and may be painful. There is no exposure of underlying bone, tendon, or muscle.
Key features of Stage 2 pressure injuries that align with the patient's presentation:
Red, blistered area: This is a hallmark sign of Stage 2, indicating tissue damage and inflammation in the epidermis and dermis. Large size: The size of the wound suggests more extensive tissue damage, consistent with Stage 2 rather than Stage 1.
Absence of deeper tissue involvement: The absence of exposed bone, tendon, or muscle rules out Stage 3 or 4 pressure injuries.
Rationales for other choices:
Choice B: Stage 4
Stage 4 pressure injuries involve full-thickness tissue loss with exposed bone, tendon, or muscle. This is not consistent with the patient's presentation, which does not describe exposed deeper tissues.
Choice C: Stage 3
Stage 3 pressure injuries involve full-thickness tissue loss, but without exposed bone, tendon, or muscle. They often present with a deep crater-like appearance and may have undermining or tunneling. The patient's wound does not exhibit these features, making Stage 3 less likely.
Choice D: Stage 1
Stage 1 pressure injuries are characterized by intact skin with non-blanchable redness over a bony prominence. They do not involve blisters or open wounds. The patient's presentation clearly exceeds the features of Stage 1.
Correct Answer is B
Explanation
Choice A rationale:
A superficial abrasion heals by secondary intention, not primary intention.
In secondary intention healing, the wound is left open to heal from the inside out. This type of healing is typically slower and results in more scar tissue formation.
The absence of active bleeding, drainage, or debris is a positive sign, but it does not guarantee that the wound is healing by primary intention.
Choice C rationale:
The presence of thick yellow slough indicates that the wound is infected and not healing properly. This is a sign of delayed healing, not primary intention healing.
Choice D rationale:
The presence of granulation tissue is a sign of healing, but it does not indicate whether the wound is healing by primary or secondary intention.
Granulation tissue is a type of new tissue that forms during the healing process. It is composed of blood vessels, collagen, and fibroblasts.
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