Which nursing action is most important after administering nitroglycerin sublingually?

Monitoring the client’s respiratory rate and effort.

Warning the client to lie still to prevent a headache.

Determining whether chest pain has been relieved.

Verifying that the sublingual tablet produced a tingling sensation.

Answer and Explanation

The Correct Answer is C

Determining whether chest pain has been relieved. This is because nitroglycerin is a medication that is used to treat chest pain caused by cardiac origin or acute pulmonary edema. The main action of nitroglycerin is to relax and dilate the blood vessels, which reduces the workload of the heart and improves blood flow to the heart muscle.

Therefore, the most important nursing action after administering nitroglycerin sublingually is to assess if the chest pain has subsided or not.

Choice A is wrong because monitoring the client’s respiratory rate and effort is not the most important action after giving nitroglycerin. Although nitroglycerin can cause hypotension and bradycardia, which may affect the respiratory status, these are side effects that can be managed and are not life-threatening as chest pain.

Choice B is wrong because warning the client to lie still to prevent a headache is not a priority after giving nitroglycerin. Nitroglycerin can cause headache as a side effect, but this can be treated with analgesics and does not require the client to lie still. Moreover, lying still may increase the risk of venous thromboembolism in a client with peripheral vascular disease.

Choice D is wrong because verifying that the sublingual tablet produced a tingling sensation is not essential after giving nitroglycerin.

Although some sublingual tablets may produce a tingling sensation, this is not a reliable indicator of the drug’s effectiveness

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Correct Answer is ["D"]

Explanation

Older adults do not have a different pain mechanism and do not feel it as much as younger individuals. This statement is false and indicates the need for further education regarding pain management in older adults.

Some possible explanations for the other choices are:

Choice A is true because older adults often fear becoming addicted to pain medications and may underreport or deny their pain.

Choice B is true because older adults often take numerous drugs that can cause interactions with pain medications and increase the risk of adverse effects.

Choice C is true because confusion and delirium can be a more common reaction to certain pain medications in the elderly, especially opioids and benzodiazepines.

Normal ranges for vital signs in older adults are similar to those in younger adults, except for blood pressure, which may be higher due to arterial stiffness. The normal range for blood pressure in older adults is 120/80 to 140/90 mm Hg.

A. High self-esteem. B. Antisocial personality traits. C. Good communication skills. D. Aggressive behaviors.

Correct Answer is B

Explanation

According to the Addiction Nursing Competencies, antisocial personality traits are one of the risk factors for developing addictive behaviors.

Antisocial personality disorder is characterized by a disregard for the rights and feelings of others, impulsivity, deceitfulness, and lack of remorse.

Choice A is wrong because high self-esteem is not associated with addictive behaviors. On the contrary, low self-esteem, passivity, and inability to relax or defer gratification are some of the personality factors that can predispose a person to substance use disorders.

Choice C is wrong because good communication skills are not related to addictive

behaviors. In fact, poor communication skills, social isolation, and lack of support are some of the psychosocial factors that can contribute to substance use disorders.

Choice D is wrong because aggressive behaviors are not a specific indicator of addictive behaviors.

Aggression can be a result of various factors, such as frustration, anger, stress, or mental illness. Aggression can also be influenced by the type and amount of substance used.

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Which nursing action is most important after administering nitroglycerin sublingually?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which statement by the student nurse indicates the need for further education regarding pain management in older adults? (Select all that apply).

Correct Answer is ["D"]

Explanation

When evaluating a client for a tendency toward addictive behaviors, the nurse would expect which findings?

Correct Answer is B

Explanation

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