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 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.

A. A client who has a headache following a grade 1 concussion. B. A client who has experienced brain death and is awaiting organ procurement. C. A client who has a score of 10 on the Glasgow Coma Scale following a motor vehicle crash. D. A client who has a score of 0 on the NIH Stroke Scale following a transient ischemic attack.

Correct Answer is C

Explanation

Choice A reason: A headache following a grade 1 concussion, while requiring monitoring, does not typically necessitate immediate proximity to the nurses' station. Grade 1 concussions are considered mild and usually do not involve loss of consciousness.

Choice B reason: A client who has experienced brain death and is awaiting organ procurement will not benefit from being close to the nurses' station due to the irreversible nature of brain death. The care for such a client is focused on maintaining organ viability for transplantation.

Choice C reason: A client with a score of 10 on the Glasgow Coma Scale following a motor vehicle crash should be placed closest to the nurses' station. A GCS score of 10 indicates a moderate level of impairment in consciousness and potentially unstable vital signs, requiring close monitoring and rapid nursing intervention.

Choice D reason: A score of 0 on the NIH Stroke Scale indicates no observable neurological deficit. Clients with a transient ischemic attack (TIA) and a score of 0 would require less intensive observation compared to those with higher scores or other acute neurological injuries.

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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 has dementia. Which of the following interventions should the nurse plan to include?

Correct Answer is A

Explanation

A charge nurse on a neurological unit is making room assignments for a group of clients. Which of the following clients should the nurse assign to the room closest to the nurses' station?

Correct Answer is C

Explanation

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