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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. AST and ALT are liver enzymes, primarily used to assess liver function, not directly related to monitoring heparin therapy.

B. Prothrombin time (PT) is used to monitor warfarin therapy, not heparin. Heparin therapy is typically monitored with aPTT, whereas warfarin is monitored with PT/INR.

C. Heparin is an anticoagulant that works by inhibiting clotting factors, and the aPTT is used to monitor its effectiveness. The aPTT measures the time it takes for blood to clot and helps ensure the heparin dose is therapeutic without causing excessive bleeding. The typical therapeutic range for aPTT on heparin therapy is 1.5 to 2.5 times the normal value.

D. INR is used to monitor warfarin therapy, not heparin. Heparin does not affect INR levels.

A. Venous insufficiency B. Intermittent claudication C. Neuropathy D. Deep vein thrombosis

Correct Answer is B

Explanation

A. Venous insufficiency results in symptoms such as swelling, aching, or heaviness, especially in the lower legs, but does not typically cause pain with exertion that is relieved by rest.

B. Intermittent claudication refers to pain and cramping in the legs that occurs during physical activity (like walking) due to reduced blood flow, which is relieved by rest. This is a hallmark symptom of peripheral arterial disease (PAD).

C. Neuropathy refers to nerve damage, often seen in conditions like diabetes, and is usually characterized by tingling, numbness, or burning sensations, not cramping or pain relieved by rest.

D. Deep vein thrombosis (DVT) presents with swelling, redness, warmth, and possible pain in the affected leg due to blood clot formation, not cramping with exertion.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is reviewing laboratory values for a client receiving a continuous heparin infusion. Which of the following laboratory values should the nurse monitor?

Correct Answer is C

Explanation

The nurse is assessing a client diagnosed with peripheral arterial disease. The client reports leg pain and cramping after walking 3 blocks, which is relieved when the client stops and rests. The nurse documents that the client is experiencing which clinical manifestation?

Correct Answer is B

Explanation

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