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 D
Explanation
A. Electrode patches relate to ECG, not TEE.
B. Keeping a leg straight is relevant for procedures involving femoral access, like cardiac catheterization.
C. Lying quietly on one side is not specific to TEE preparation.
D. Sedation helps patients tolerate the TEE, which involves passing a probe down the esophagus.
Correct Answer is A
Explanation
A. Troponins (specifically troponin I and T) are proteins released when the heart muscle is damaged. They are the most specific and sensitive markers for myocardial injury, especially in diagnosing a myocardial infarction (MI).
B. Creatine kinase (CK) is an enzyme found in various tissues, including the heart. CK-MB is a cardiac isoenzyme, but it is not as specific for myocardial injury as troponins. It can also be elevated in other conditions like muscle injury.
C. Homocysteine (Hcy) is an amino acid that can increase the risk of cardiovascular disease but does not serve as an immediate marker for myocardial damage.
D. Myoglobin is an early marker of muscle injury, but it lacks specificity for myocardial damage as it can also rise in skeletal muscle injury, making it less reliable than troponins.
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