The nurse is caring for a patient experiencing severe chest pain. Five minutes after administering the nitroglycerin 0.4 mg sublingually, the client states no change at all in his pain level. The next immediate nursing action is which of the following?

Call the physician.

Administer a second nitroglycerin 4mg tablet sublingually.

Increase the oxygen level to 4L via nasal cannula.

Re-check vital signs.

Answer and Explanation

The Correct Answer is D

A. Calling the physician is important if the patient’s condition worsens or if the chest pain persists after the full protocol of nitroglycerin administration (usually up to 3 doses, 5 minutes apart). However, this is not the immediate next action.
B. Incorrect dosage. The standard dose of sublingual nitroglycerin is 0.4 mg. Giving 4 mg would be a serious overdose and unsafe.
C. Increasing oxygen might be appropriate if the patient is hypoxic (e.g., low O₂ saturation), but this is not automatically done without assessing vitals first.
D. Before administering a second dose of nitroglycerin, it is essential to re-check the patient’s blood pressure and other vital signs. Nitroglycerin can cause hypotension, and giving another dose without verifying stability can be dangerous.

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Correct Answer is A

Explanation

A. Hematocrit (Hct): Epoetin alfa is a synthetic form of erythropoietin, a hormone that stimulates the production of red blood cells (RBCs) in the bone marrow. In patients with chronic renal disease, epoetin alfa is used to treat anemia, which is common due to the kidneys' reduced ability to produce erythropoietin. A therapeutic effect of epoetin alfa would be an increase in hematocrit (Hct), reflecting an improvement in RBC production and a reduction in anemia.

B. Erythrocyte Sedimentation Rate (ESR): ESR is a nonspecific marker of inflammation or infection, not an indicator of red blood cell production. While chronic renal disease may cause inflammation, an increase in ESR is not a therapeutic effect of epoetin alfa.

C. Platelets: Epoetin alfa primarily stimulates the production of red blood cells, not platelets. An increase in platelets would not be a therapeutic effect of epoetin alfa and could indicate another issue, such as a bone marrow disorder or infection.

D. Leukocytes: Epoetin alfa does not affect the production of white blood cells (leukocytes). An increase in leukocytes could indicate an infection or other condition, but it is not related to the therapeutic action of epoetin alfa.

A. remove the chest tube and cover the incision site with a sterile petrolatum gauze. B. disconnect the drainage system covering the catheter tip with sterile gauze. C. send the client to x-ray with the chest tube clamped. D. send the client to x-ray with the chest tube attached to the drainage system

Correct Answer is D

Explanation

A. Remove the chest tube and cover the incision site with a sterile petrolatum gauze: Removing the chest tube is not appropriate for transporting the patient to the x-ray department. The chest tube is essential for draining air, blood, or fluid from the pleural space and preventing complications like pneumothorax or fluid buildup. Removing it could cause harm and disrupt the treatment.

B. Disconnect the drainage system covering the catheter tip with sterile gauze: Disconnecting the drainage system is not recommended as it could cause the re-accumulation of air or fluid in the pleural space and compromise the patient's condition. The chest tube should remain connected to the drainage system to ensure continued drainage and prevent complications.

C. Send the client to x-ray with the chest tube clamped: Clamping a chest tube is not recommended unless specifically directed by a healthcare provider (such as during certain procedures or trials). Clamping can lead to dangerous complications, such as a tension pneumothorax, by preventing proper drainage of air or fluid. Therefore, the chest tube should not be clamped during transport.

D. Send the client to x-ray with the chest tube attached to the drainage system: This is the correct answer. The chest tube should remain attached to the drainage system during transport to ensure continuous drainage of air or fluid from the pleural space, which is vital for the patient's stability. The drainage system should be securely positioned to avoid kinks or disconnections, and the chest tube should remain open to prevent complications.

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The nurse is caring for a patient experiencing severe chest pain. Five minutes after administering the nitroglycerin 0.4 mg sublingually, the client states no change at all in his pain level. The next immediate nursing action is which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has chronic renal disease and is receiving therapy with epoetin alfa. Which of the following laboratory results indicates a therapeutic effect of the medication to the nurse? An increase in....

Correct Answer is A

Explanation

To safely transport a client with chest tube drainage to the x-ray department to assess the degree of lung re-expansion, the nurse would:

Correct Answer is D

Explanation

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