When providing discharge instructions for a client who has been prescribed sublingual nitroglycerin for stable angina, the nurse should plan to include which instructions?
"Only take one nitroglycerin tablet for each episode of angina."
"Place the nitroglycerin tablet between cheek and gum."
"Call 911 if you develop a headache following nitroglycerin use."
"See if rest relieves the chest pain before using the nitroglycerin."
The Correct Answer is A
A. "Only take one nitroglycerin tablet for each episode of angina."
This instruction is correct. Sublingual nitroglycerin is typically administered as needed for the relief of angina symptoms, with one tablet being the initial dose. If the chest pain persists after 5 minutes, the client may take a second tablet, and if needed, a third tablet after another 5 minutes. However, if the pain is not relieved after three tablets, they should seek immediate medical attention.
B. "Place the nitroglycerin tablet between cheek and gum."
This instruction is incorrect. Sublingual nitroglycerin tablets should be placed under the tongue, allowing them to dissolve and be absorbed directly into the bloodstream. Placing the tablet between the cheek and gum is not the recommended administration route for sublingual nitroglycerin.
C. "Call 911 if you develop a headache following nitroglycerin use."
This instruction is partially correct. Headache is a common side effect of nitroglycerin due to its vasodilatory effects. Clients should be informed about this potential side effect, but not every headache following nitroglycerin use requires immediate medical attention. However, if the headache is severe, persistent, or accompanied by other concerning symptoms, the client should seek medical evaluation.
D. "See if rest relieves the chest pain before using the nitroglycerin."
This instruction is incorrect. Sublingual nitroglycerin is a rapid-acting medication used to relieve angina symptoms quickly. Clients should not delay taking nitroglycerin and wait for rest to relieve chest pain, as this can lead to worsening symptoms and complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Administer aspirin:
Aspirin is commonly given to patients suspected of having a heart attack because it helps to inhibit platelet aggregation and reduce the risk of further clot formation. However, the administration of aspirin typically follows the confirmation of a cardiac event through diagnostic tests like the ECG. Aspirin is not the initial priority compared to obtaining diagnostic data.
B. 12 Lead Electrocardiography (ECG):
This is the most critical and time-sensitive action because it helps to quickly assess the patient's cardiac status. A 12 Lead ECG can identify important findings such as ST-segment elevation or depression, which are indicative of acute myocardial infarction (heart attack) or other cardiac abnormalities. Early detection and intervention are crucial in improving outcomes for patients with suspected cardiac events.
C. Assess vital signs:
Vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, provide valuable information about the patient's overall condition and can help determine the severity of the cardiac event. While assessing vital signs is important, performing the ECG takes precedence due to its immediate relevance in diagnosing and managing a potential cardiac emergency.
D. Administer morphine:
Morphine may be indicated for pain relief in patients with acute coronary syndromes. However, its administration should be based on the patient's pain level, hemodynamic stability, and other factors assessed after obtaining the ECG and vital signs. Morphine administration is not the primary action within the first 10 minutes of the patient's arrival; it follows the initial assessment and diagnostic procedures.
Correct Answer is B
Explanation
A. "The decreased HDL level will increase the amount of cholesterol moved away from the artery walls":
This statement is incorrect. High-density lipoprotein (HDL) is often referred to as "good" cholesterol because it helps remove excess cholesterol from the bloodstream and transport it to the liver for processing. A decreased HDL level is associated with an increased risk of cardiovascular disease, not with moving cholesterol away from artery walls.
B. "Increased LDL and decreased HDL increase my risk of coronary artery disease":
This statement is correct. Low-density lipoprotein (LDL) is often referred to as "bad" cholesterol because elevated LDL levels contribute to the buildup of plaque in the arteries, increasing the risk of coronary artery disease (CAD). Conversely, decreased HDL levels are associated with reduced cholesterol removal from the bloodstream, further increasing the risk of CAD.
C. "Increased LDL has the potential to decrease my risk of heart disease":
This statement is incorrect. Elevated LDL levels are a major risk factor for heart disease and are associated with an increased risk of atherosclerosis and cardiovascular events.
D. "The increased LDL will decrease the amount of cholesterol deposited on the artery walls":
This statement is incorrect. Increased LDL levels contribute to the deposition of cholesterol on artery walls, leading to the formation of plaque and narrowing of the arteries, which is detrimental to heart health.
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