nurse is caring for a client who is newly-admitted and has angina. The client asks the nurse, "Why am I taking nitroglycerin?" Which of the lowing responses should the nurse make?
"Nitroglycerin dilates cardiac blood vessels to deliver more oxygen to the heart."
"Nitroglycerin relieves nausea and prevents vomiting, which could lead to aspiration."
"Nitroglycerin acts as a bronchodilator to open small airways and decrease shortness of breath."
"Nitroglycerin decreases chest pain by dissolving blood clots that are occluding the arteries."
The Correct Answer is A
A. "Nitroglycerin dilates cardiac blood vessels to deliver more oxygen to the heart." Nitroglycerin works by dilating the coronary arteries, increasing blood flow and oxygen delivery to the heart muscle, thereby reducing angina.
B. "Nitroglycerin relieves nausea and prevents vomiting, which could lead to aspiration." Nitroglycerin does not have an antiemetic function or impact nausea and vomiting.
C. "Nitroglycerin acts as a bronchodilator to open small airways and decrease shortness of breath." Nitroglycerin is not a bronchodilator. It does not act on the airways but instead works on blood vessels.
D. "Nitroglycerin decreases chest pain by dissolving blood clots that are occluding the arteries." Nitroglycerin does not dissolve blood clots. Thrombolytic agents are used for clot dissolution, not nitroglycerin.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. S3 heart sound: An S3 heart sound is often associated with heart failure and volume overload, not specifically mitral stenosis.
B. Dyspnea on exertion: Dyspnea on exertion is a classic symptom of mitral stenosis. The narrowing of the mitral valve restricts blood flow from the left atrium to the left ventricle, causing pulmonary congestion and shortness of breath, especially during physical activity.
C. Cyanosis: While cyanosis can occur in advanced stages of heart disease, it is not a primary symptom of mitral stenosis. It indicates severe oxygenation issues, which are usually late findings.
D. S4 heart sound: An S4 heart sound is typically associated with left ventricular hypertrophy, which can occur in advanced cases of mitral stenosis. However, it's not a specific early manifestation of the condition.
Correct Answer is D
Explanation
A. Tell the client to take another nitroglycerin tablet in 15 minutes. Nitroglycerin can be taken every 5 minutes, up to three doses, for chest pain. Waiting 15 minutes to take another dose is too long and can delay necessary treatment.
B. Advise the client to take an antacid. Antacids are not appropriate for managing chest pain that may be related to angina or a myocardial infarction. This response may delay critical treatment.
C. Advise the client to come into the office. This would delay care in a potential emergency situation. If the client is experiencing unrelieved chest pain after taking nitroglycerin, immediate emergency care is necessary.
D. Instruct the client to call 911. Chest pain unrelieved by nitroglycerin is a sign of a possible myocardial infarction, which is a medical emergency. The client should call 911 immediately to receive urgent care.
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