The nurse is instructing the client on the correct way to take nitroglycerin as needed for chest pain:

Two tablets PO (by mouth) every 15 minutes.

One tablet SL (sublingual) every 15 minutes, up to 5 times.

One tablet PO (by mouth) every one hour, up to 5 times.

One tablet SL (sublingual) every 5 minutes, up to 3 times.

Answer and Explanation

The Correct Answer is D

Choice A reason: Taking two tablets PO every 15 minutes is not the standard protocol for nitroglycerin administration for chest pain. This method could lead to an overdose and significant hypotension (low blood pressure), which can be dangerous.

Choice B reason: One tablet SL every 15 minutes, up to 5 times, is also not the standard protocol. While sublingual administration is correct, the frequency and the total number of doses are higher than recommended, which could result in adverse effects such as headache, dizziness, or a severe drop in blood pressure.

Choice C reason: One tablet PO every one hour, up to 5 times, is not a recommended method for acute chest pain relief from angina. Oral administration does not provide the rapid onset of action required for acute angina relief.

Choice D reason: One tablet SL every 5 minutes, up to 3 times, is the correct protocol for nitroglycerin administration when experiencing chest pain due to angina. If pain persists after the first dose, the patient can take a second dose after 5 minutes, and if needed, a third dose after another 5 minutes. If chest pain continues after three doses in 15 minutes, emergency medical help should be sought immediately.

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Correct Answer is C

Explanation

Choice A reason: Checking the client's blood pressure every 8 hours is important, but it is not as critical as monitoring urine output in the immediate postoperative period. Blood pressure should be monitored regularly, but changes in urine output can provide more immediate information about the new kidney's function.

Choice B reason: Monitoring for hypokalemia is important, as it can be a sign of acute rejection; however, hyperkalemia is more commonly associated with acute rejection due to the kidney's inability to excrete potassium. Therefore, while electrolyte monitoring is crucial, the focus is typically on hyperkalemia rather than hypokalemia.

Choice C reason: Assessing urine output hourly is essential for a client who has undergone a kidney transplant. Urine output is a direct indicator of the new kidney's function, and any significant decrease could indicate a complication such as acute rejection or obstruction.

Choice D reason: Administering opioids orally for pain management is part of postoperative care, but it is not the priority over monitoring urine output and kidney function.

A. Place the client's bed at the lowest height. B. Request a prescription for a nightly sedative. C. Assist the client with toileting at least once every 4 hours. D. Turn off all lights in the client's room at night.

Correct Answer is A

Explanation

Choice A reason: Placing the client's bed at the lowest height is a safety intervention that minimizes the risk of injury from falls, which is particularly important for clients with dementia who may have impaired mobility or judgment. Lowering the bed height can reduce the severity of an injury if a fall does occur. Additionally, it can facilitate easier access for the client to get in and out of bed with less assistance.

Choice B reason: Requesting a prescription for a nightly sedative is not typically recommended as a first-line intervention for clients with dementia. Sedatives can increase the risk of confusion, falls, and can worsen cognitive impairment in the elderly. Non-pharmacological approaches are preferred for managing sleep disturbances in dementia patients.

Choice C reason: Assisting the client with toileting at least once every 4 hours is an important intervention to maintain hygiene and comfort, as well as to prevent urinary tract infections and skin breakdown. However, the frequency of toileting assistance should be individualized based on the client's needs and level of incontinence.

Choice D reason: Turning off all lights in the client's room at night is not advisable as some clients with dementia may experience increased confusion or agitation in complete darkness. A nightlight or low-level lighting can provide a safer environment and help to orient the client during nighttime hours.

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The nurse is instructing the client on the correct way to take nitroglycerin as needed for chest pain:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is 12 hours postoperative following a kidney transplant. Which of the following actions should the nurse include in the plan of care?

Correct Answer is C

Explanation

A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse plan to include?

Correct Answer is A

Explanation

A nurse is teaching a client who has left-sided weakness how to use a quad cane. Which of the following client actions indicates an understanding of the teaching?

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The nurse is caring for several clients on a hospital unit. Which of the following clients is most at risk for hypoglycemia?

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