The nurse has finished teaching a patient diagnosed with chronic stable angina about the use of sublingual nitroglycerin (Nitrostat). Which patient statement indicates that the teaching has been effective?
"Nitroglycerin can only be taken after chest pain occurs, never on a schedule or preventatively.
"I can expect headache as the main side effect of nitroglycerin.7
will call an ambulance if I still have pain after taking three nitroglycerin 5 minutes apart
"Nitroglycerin may decrease my respiratory rate.
The Correct Answer is C
A. Nitroglycerin is often taken preventatively before activities that may trigger chest pain, in addition to being used when chest pain occurs. The statement is incorrect because nitroglycerin can be used both preventatively and acutely.
B. A headache is a common side effect of nitroglycerin due to vasodilation. However, the client’s primary concern should be relief of chest pain, and the statement does not demonstrate a proper response to the medication’s therapeutic effect.
C. This statement indicates understanding of the correct action if chest pain is unrelieved after taking the maximum recommended dose of nitroglycerin (three tablets, 5 minutes apart). If pain persists, it may indicate a myocardial infarction, and the client should seek emergency medical help immediately by calling an ambulance.
D. Nitroglycerin may cause vasodilation and potentially reduce respiratory rate, but it does not directly reduce the respiratory rate in a therapeutic sense. This statement misrepresents the expected effect of the drug.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Taking another nitroglycerin tablet without medical supervision is inappropriate and can lead to unsafe drops in blood pressure. This situation requires immediate evaluation by emergency services.
B. Advising the client to come to the office is not appropriate because the client needs immediate emergency care, which cannot be provided in a typical provider’s office.
C. Nitroglycerin is typically used to relieve chest pain from angina, but if the pain persists after taking it, this may indicate a myocardial infarction (MI). The client should call 911 immediately for emergency medical care as chest pain not relieved by nitroglycerin is a critical sign.
D. Antacids are not appropriate for chest pain associated with possible MI, as this pain is not due to acid reflux. Immediate medical intervention is necessary.
Correct Answer is C
Explanation
A. Temperature is not directly related to the effects of nitroglycerin or the client’s need for additional doses.
B. While oxygen saturation is important, it does not directly influence the decision to administer nitroglycerin, which primarily works to relieve chest pain by dilating coronary arteries and reducing myocardial oxygen demand.
C. Nitroglycerin is a vasodilator that can lower blood pressure. It is crucial to check the client’s blood pressure before administering another dose of nitroglycerin because excessive drops in blood pressure can lead to dizziness, fainting, or other complications. If the blood pressure is already low, further administration may be contraindicated.
D. Apical pulse rate is important to monitor but is not the most critical cue in this scenario. Nitroglycerin primarily affects blood pressure and coronary circulation rather than directly influencing heart rate.
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