The nurse is caring who presented with unstable angina. Before giving the client, a dose of sublingual nitroglycerin, which action should the nurse take?

Auscultate the client’s apical pulse for a full minute

Advise the client that vomiting is primary side effect

Check the client’s blood pressure

Obtain a STAT chest X-ray

Answer and Explanation

The Correct Answer is C

A. Auscultate the client’s apical pulse for a full minute:
While auscultating the apical pulse is important for certain cardiovascular conditions, it is not the primary action needed before administering sublingual nitroglycerin. The nurse's main priority is to assess the patient's blood pressure, as nitroglycerin can cause significant hypotension (a drop in blood pressure), and it is important to ensure the patient’s blood pressure is adequate before administration. If the blood pressure is too low, nitroglycerin should not be given.

B. Advise the client that vomiting is a primary side effect:
Vomiting is not a primary or common side effect of sublingual nitroglycerin. Nitroglycerin is more likely to cause headaches, dizziness, flushing, and hypotension. While it’s helpful to inform the patient about possible side effects, advising them that vomiting is a primary side effect could cause unnecessary concern or confusion.

C. Check the client’s blood pressure:
This is the correct action. Nitroglycerin works by dilating blood vessels, which can lower blood pressure. Before administering sublingual nitroglycerin, it is essential to check the client's blood pressure. If the client is hypotensive or has low blood pressure, nitroglycerin should be withheld, as it could further decrease blood pressure and worsen the patient’s condition. This is the priority nursing action to ensure the patient’s safety.

D. Obtain a STAT chest X-ray:
Obtaining a chest X-ray is not a priority action for a client with unstable angina before administering nitroglycerin. Chest X-rays are more useful for diagnosing conditions like pneumonia, pneumothorax, or other structural issues of the chest, but they are not immediately needed in the management of unstable angina. The most immediate concern is assessing the patient’s blood pressure before administering nitroglycerin.

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Correct Answer is B

Explanation

A) Fasting plasma glucose of 98 mg/dl:
A fasting plasma glucose level of 98 mg/dl is within the normal range (70–99 mg/dl). According to diagnostic criteria, a fasting plasma glucose level of 100–125 mg/dl is considered prediabetes, and 126 mg/dl or higher on two separate occasions is diagnostic for diabetes. Therefore, a fasting plasma glucose of 98 mg/dl is not diagnostic for diabetes.

B) Hemoglobin A1C (glycosylated hemoglobin) of 7.2%:
An HbA1C level of 7.2% is diagnostic for diabetes. The American Diabetes Association (ADA) defines diabetes as an HbA1C of 6.5% or higher. The HbA1C test reflects the average blood glucose level over the past 2–3 months, and a level of 7.2% indicates that the patient's blood glucose levels have been elevated over time, consistent with diabetes. This is a key diagnostic criterion.

C) Random plasma glucose of 110 mg/dl:
Although a random glucose value greater than 200 mg/dl with symptoms of hyperglycemia can be diagnostic of diabetes, 110 mg/dl is within the normal range and does not meet the criteria for a diabetes diagnosis. For diagnostic purposes, a random plasma glucose must be 200 mg/dl or higher.

D) Two hour plasma glucose of 140 mg/dl:
For the test to be diagnostic of diabetes, the plasma glucose must be 200 mg/dl or higher after two hours. A level of 140 mg/dl suggests normal glucose tolerance or prediabetes, but it is not diagnostic for diabetes.

Correct Answer is ["250"]

Explanation

Given:

Total volume to infuse: 250 mL

Infusion time: 60 minutes

To find:

Infusion rate (mL/hr)

Step 1: Calculate the infusion rate in mL/min

Infusion rate (mL/min) = Total volume / Infusion time

Infusion rate (mL/min) = 250 mL / 60 minutes = 4.17 mL/min

Step 2: Convert mL/min to mL/hr

Infusion rate (mL/hr) = Infusion rate (mL/min) x 60 minutes/hr

Infusion rate (mL/hr) = 4.17 mL/min x 60 minutes/hr = 250 mL/hr

Therefore, the nurse should set the pump to deliver 250 mL/hr.

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The nurse is caring who presented with unstable angina. Before giving the client, a dose of sublingual nitroglycerin, which action should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Explanation

Correct Answer is ["250"]

Explanation

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