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Patient Data

The nurse has provided discharge teaching to the client to manage his chest pain at home. Which 2 statements from the client should the nurse recognize as a need for further education?

I will chew my nitroglycerin tabs as soon as pain begins.

I will lie down or sit if I start to feel any chest discomfort.

I will keep my nitroglycerin tablets with me all the time.

I will call 911 if there is no improvement in my chest pain after taking nitroglycerin.

I will wear a medication alert bracelet to indicate my history of heart problems.

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.

Answer and Explanation

Correct Answer : A,F

A. Nitroglycerin is highly susceptible to the "first-pass effect," meaning if it is swallowed or chewed and enters the digestive system, the liver will metabolize and inactivate it before it reaches the heart. It must be administered sublingually (under the tongue) to be absorbed directly into the systemic circulation through the oral mucosa.

B. Nitroglycerin is a potent vasodilator. A common side effect is a sudden drop in blood pressure (orthostatic hypotension), which can cause dizziness, syncope (fainting), and falls. Sitting or lying down before taking the medication ensures patient safety. Additionally, resting reduces the oxygen demand on the heart.

C. Anginal pain often occurs during physical exertion or emotional stress (as seen when the patient was mowing the lawn). Immediate access to the medication is critical to stop the progression of ischemia and prevent myocardial infarction.

D. If the pain does not subside after the first dose, it may indicate a myocardial infarction (heart attack) rather than stable angina. Timely activation of Emergency Medical Services (EMS) is the most critical step in reducing heart muscle damage.

E. In the event the patient becomes unconscious or unresponsive, a medical alert bracelet provides first responders with vital information regarding his cardiac history and medications, allowing for faster and more accurate emergency treatment.

F. This statement contains two errors. First, the interval between doses should be 5 minutes, not 10. Second, the patient should not wait to take three doses before calling 911. Current guidelines suggest calling 911 if pain is unrelieved or worsening 5 minutes after the first dose.

G. Sublingual nitroglycerin typically begins to work within 1 to 3 minutes. Waiting 5 minutes allows enough time for the medication to reach peak effect before deciding if an additional dose or emergency intervention is required.

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Correct Answer is C

Explanation

A. Giving the spouse a straw to help the client drink is premature and potentially dangerous. After a cerebrovascular accident (CVA), clients with facial paralysis and hemiplegia are at high risk for dysphagia, and the use of a straw could increase the likelihood of aspiration. Aspiration can lead to serious complications such as pneumonia or airway obstruction, so it is unsafe to provide fluids in this manner without first assessing swallowing ability.

B. Obtaining thickening powder before offering fluids may be necessary later if the client is cleared for oral intake, but this step does not address the immediate concern. The client may not yet be safe to take any fluids by mouth. Administering thickened liquids without a swallowing assessment could still result in choking or aspiration if the client cannot coordinate swallowing effectively.

C. Asking the spouse to stop and assessing the client’s swallowing reflex is the correct and priority action. The nurse must ensure the client can safely swallow before allowing any oral intake. Swallowing assessment includes evaluating the gag reflex, observing for coughing, drooling, or difficulty managing saliva, and determining the client’s ability to handle liquids safely. This step protects the client from aspiration, which is a common and potentially life-threatening complication following a CVA. Once the assessment is completed, the nurse can determine whether safe feeding strategies, such as thickened liquids or modified feeding techniques, are appropriate.

D. Assisting the spouse to give small sips of water without assessing swallowing is unsafe. Although the intention is to support hydration, providing fluids to a client with potential dysphagia can result in choking, aspiration, and subsequent respiratory complications. Safety must take precedence over immediate hydration in this scenario.

Correct Answer is []

Explanation

Rationale for Correct Choices
• Risk for contracting communicable diseases: The infant missed her 2-month vaccinations and is in contact with an immunocompromised grandmother and attends daycare, increasing risk of exposure to vaccine-preventable illnesses.
• Consult social services for assistance: Addressing barriers such as transportation and financial hardship supports adherence to preventive care, ensuring timely immunizations and follow-up visits.
• Begin administration of missed immunizations and establish an adjusted timeline as needed: Catch-up immunization schedule is essential to protect the infant from communicable diseases and prevent outbreaks, especially given her high-risk environment.
• Vaccine administration: Monitoring ensures the infant receives all recommended vaccines on the adjusted schedule, preventing gaps in protection.
• Keeping scheduled visits: Tracking adherence to wellness visits ensures ongoing assessment of growth, development, and preventive care, reducing the risk of missed vaccines or delayed interventions.

Rationale for Incorrect Choices
• Failure to thrive: Current weight and growth appear appropriate for age; no signs of malnutrition or inadequate intake are noted.
• Anemia: No clinical signs (pallor, lethargy) or laboratory data suggest anemia at this time.
• Child abuse: No indications of neglect, injury, or unsafe living conditions are reported; missed vaccinations are due to socioeconomic barriers, not abuse.
• Start NG tube feedings: Infant is feeding orally without difficulty; NG feeding is unnecessary.
• Administer pain medication: No pain or distress noted; pain management is not indicated.
• Hemoglobin and hematocrit: Not immediately indicated as there is no clinical concern for anemia.
• Developmental milestones: Normal for age; no delay reported, though continued monitoring is appropriate.
• Weight: Currently tracking weight is important but the infant is gaining appropriately; risk is minimal

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Patient Data The nurse has provided discharge teaching to the client to manage his chest pain at home. Which 2 statements from the client should the nurse recognize as a need for further education?

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Correct Answer is C

Explanation

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Correct Answer is []

Explanation

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Patient Data

The nurse has provided discharge teaching to the client to manage his chest pain at home. Which 2 statements from the client should the nurse recognize as a need for further education?