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 C

Explanation

The nurse should complete an incident report when he or she contaminates and discards two indwelling catheters during the insertion procedure. This is because an incident report is a tool for documenting any event that is not consistent with the routine operation of a health care unit or the routine care of a client. An incident report helps to identify potential risks and improve quality and safety.

Choice A is wrong because not completing the care plan for a newly admitted client before leaving the unit is not an incident that requires reporting.

It is a matter of time management and prioritization.

Choice B is wrong because recording a client’s refusal to take prescribed medication on the chart is not an incident that requires reporting.

It is a part of the nursing documentation and communication.

Choice D is wrong because experiencing back pain after moving a client up in the bed is not an incident that requires reporting.

It is a personal injury that may be related to improper body mechanics or ergonomics.

A. Hives. B. Itching. C. Vomiting. D. Abdominal distension.

Correct Answer is B

Explanation

This is because itching is a subjective assessment finding, which means it is based on the personal experience, view or feeling of the

patient. The other choices are objective assessment findings, which means they are based on observable or measurable data that the nurse can collect.

For example:

Choice A is wrong because hives are a visible skin reaction that can be seen and measured by the nurse.

Choice C is wrong because vomiting is an observable action that can be verified and recorded by the nurse.

Choice D is wrong because abdominal distension is a measurable change in the size or shape of the abdomen that can be assessed by the nurse.

Normal ranges for objective assessment findings may vary depending on the source and context, but some possible examples are:

Hives: No hives or rashes on the skin are normal.
Vomiting: No vomiting or nausea are normal.
Abdominal distension: Normal abdominal girth for adults ranges from 68 to 100 cm (27 to 40 inches).

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Which nursing action is most important after administering nitroglycerin sublingually?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which situation requires a nurse to complete an incident report? The nurse:.

Correct Answer is C

Explanation

Which of these assessment findings should a nurse record as subjective?

Correct Answer is B

Explanation

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