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 ["A","C","D"]

Explanation

The correct answers are:

A. You may start taking warfarin while still on heparin when you are getting ready to be discharged home.

Warfarin takes several days to reach therapeutic levels, so patients often overlap with heparin until the INR (International Normalized Ratio) reaches the target range (typically 2.0-3.0 for most conditions).

C. Use a soft-bristled toothbrush and avoid brushing too aggressively.

Warfarin increases the risk of bleeding, so using a soft toothbrush helps prevent gum bleeding.

D. You should replace straight razors with an electric shaver to avoid cuts.

Since warfarin thins the blood, small cuts can lead to excessive bleeding. An electric shaver reduces the risk of accidental cuts.

B. You will need to have your aPTT monitored frequently while on Warfarin. (Incorrect)

Warfarin is monitored using INR and PT (Prothrombin Time), not aPTT.
aPTT (Activated Partial Thromboplastin Time) is used to monitor heparin therapy, not warfarin.

E. Increase foods high in vitamin K like dark green leafy vegetables while taking Warfarin. (Incorrect)

Vitamin K counteracts warfarin's effects, so patients should keep their vitamin K intake consistent rather than increasing it.

A. 2-6 hours before meals. B. Lispro lasts 24 hours and does not have to be timed with meals. C. 15-30 minutes before meals. D. 60 minutes before meals.

Correct Answer is B

Explanation

A. 2-6 hours before meals:
This timeframe is too long for rapid-acting insulin like Lispro. Rapid-acting insulins, such as Lispro, begin to work quickly after administration, typically within 15 minutes, and peak around 1 to 2 hours after injection. Administering it 2-6 hours before meals would not align with the timing of food intake and would likely lead to hypoglycemia before the meal. Timing of rapid-acting insulin should be closer to the meal to match the rise in blood glucose levels that occurs after eating.

B. Lispro lasts 24 hours and does not have to be timed with meals:
This statement is incorrect. Lispro is a rapid-acting insulin, and its duration of action is much shorter than 24 hours, typically lasting about 3-5 hours. It is crucial to time the administration of Lispro with meals to match its peak action with the rise in blood glucose levels after eating. A long-acting insulin would be the type that lasts for 24 hours, but that is not the case with Lispro.

C. 15-30 minutes before meals:
Lispro is a rapid-acting insulin, and its onset of action occurs within 15 minutes after injection. It is most effective when administered within 15-30 minutes before the start of a meal, as it peaks in about 1-2 hours and works to regulate blood glucose levels during and after the meal. This timing ensures that insulin works in concert with the rise in blood glucose following food intake, helping prevent hyperglycemia.

D. 60 minutes before meals:
Administering Lispro 60 minutes before a meal is too early. Rapid-acting insulins, such as Lispro, begin working quickly and reach peak action within 1-2 hours. If administered too far in advance, there is a risk that the insulin may have peaked before the meal, leading to a potential drop in blood glucose levels before the meal is consumed. This could result in hypoglycemia. Therefore, administering it closer to the meal, within 15-30 minutes, is the optimal timing.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing education for client newly prescribed warfarin in preparation for being discharged home. Which of the following should be included the teaching plan? (Select all that apply.)

Correct Answer is ["A","C","D"]

Explanation

The nurse is planning care for a client with type 1 diabetes mellitus. When planning administration for rapid-acting insulin Lispro, the nurse knows to administer it during which timeframe based on the onset of action?

Correct Answer is B

Explanation

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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