The nurse is to begin a nitroglycerin infusion for a client diagnosed with an anterior wall myocardial infarction. Which assessment finding should the nurse report to the provider immediately?

Serum potassium of 5.2 mEq/L (normal 3.5 mEq/L-5.3 mEq/L.)

T wave depression on electrocardiogram

Heart rate of 90 beats per minute

Blood pressure of 90/50

Answer and Explanation

The Correct Answer is D

A. Serum potassium of 5.2 mEq/L: A potassium level of 5.2 mEq/L is slightly elevated but is still within a potentially acceptable range (normal is 3.5-5.3 mEq/L). While elevated potassium can be a concern, particularly in the context of an MI or with certain medications (like potassium-sparing diuretics), this level is not critically high. The nurse should monitor the potassium levels, but this is not an urgent finding requiring immediate reporting unless it increases further or is accompanied by significant symptoms (such as arrhythmias).

B. T wave depression on electrocardiogram (ECG): T wave depression can be a sign of ischemia or injury, which is common in the setting of an acute myocardial infarction. However, T wave changes are expected in this context and do not indicate an immediate emergency. The nurse should continue to monitor the ECG for any progression or worsening of ischemic changes but should prioritize concerns such as hypotension or worsening clinical status over this finding.

C. Heart rate of 90 beats per minute: A heart rate of 90 beats per minute is within normal limits (60-100 beats per minute), especially in the early stages of an MI. Nitroglycerin may cause a reflex tachycardia as a compensatory response to the decreased blood pressure, but a heart rate of 90 bpm is not an alarming finding. The nurse should continue to monitor the heart rate, but it is not the most pressing concern compared to hypotension. 4o mini

D. Blood pressure of 90/50: A blood pressure of 90/50 mmHg is significantly low and could indicate that the client is experiencing hypotension, which is a known side effect of nitroglycerin infusion. Nitroglycerin causes vasodilation, which can reduce blood pressure, especially in clients who are already at risk due to an acute myocardial infarction (MI). Low blood pressure can compromise perfusion to vital organs, including the heart, brain, and kidneys, and may lead to shock if not corrected promptly. This finding should be reported immediately to the healthcare provider, as it may require adjustment of the nitroglycerin dosage or discontinuation of the infusion.

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Correct Answer is B

Explanation

A. Tizanidine is a sleep aid and used to promote sleep along with melatonin:

This is incorrect. Tizanidine is not classified as a sleep aid. While muscle relaxants like tizanidine may cause drowsiness as a side effect, its primary purpose is to reduce muscle spasms rather than to promote sleep. Using it in combination with melatonin for sleep would not be appropriate unless specifically prescribed by a healthcare provider.

B. Tizanidine is a muscle relaxant medication used to reduce muscle spasms:

Tizanidine is a centrally acting muscle relaxant that is commonly used to treat muscle spasms and spasticity. In clients with amyotrophic lateral sclerosis (ALS), spasticity can be a significant symptom, leading to muscle stiffness and discomfort. Tizanidine helps by relaxing the muscles and alleviating the muscle tightness associated with ALS. It works by inhibiting nerve impulses that cause muscles to contract, thus reducing spasticity and improving mobility. This medication is not intended for sleep promotion or pain relief directly, but rather to manage muscle spasms.

C. Tizanidine is an antibiotic medication used to treat bacterial infections:

This is incorrect. Tizanidine is not an antibiotic and has no role in treating bacterial infections. It is a muscle relaxant used for managing spasticity, not an antimicrobial drug.

D. Tizanidine is an opiate and is used to relieve severe pain:

This is incorrect. Tizanidine is not an opiate and does not belong to the class of opioids. It does not have the pain-relieving effects of opioid analgesics. While it may provide some relief from muscle discomfort, it is not used to treat severe pain in the way opiates like morphine or oxycodone are. Tizanidine’s primary purpose is to address muscle spasticity, not pain management.

Correct Answer is ["56"]

Explanation

Calculate the infusion rate in mL/min.

The total volume to be infused is 500 mL.

The infusion time is 90 minutes.

The infusion rate = 500 mL / 90 minutes = 5.5556 mL/min.

Calculate the drip rate in gtt/min.

The drop factor is 10 gtt/mL.

We need to deliver 5.5556 mL/min.

To find the drip rate, we can set up a proportion:

10 gtt / 1 mL = x gtt / 5.5556 mL

Cross-multiplying:

x = 10 gtt/mL x 5.5556 mL = 55.5556 gtt

Round the answer to the nearest whole number.

56 gtt/min.

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The nurse is to begin a nitroglycerin infusion for a client diagnosed with an anterior wall myocardial infarction. Which assessment finding should the nurse report to the provider immediately?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client diagnosed with amyotrophic lateral sclerosis (ALS). The client was given a medical prescription for tizanidine. What information would the nurse provide regarding this medication? Tizanidine is

Correct Answer is B

Explanation

A patient is prescribed 500 ml of Normal Saline to be infused over 90 minutes. The drop factor on the tubing is 10 gtt/mL. At what rate should the nurse regulate the IV (gtt/min)? (Round to the nearest whole number)

Correct Answer is ["56"]

Explanation

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