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.
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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rhonchi. Rhonchi are low-pitched, rattling sounds that indicate mucus in the larger airways. They are most evident on expiration and may decrease after coughing.
Choice B is wrong because wheezes are high-pitched, squeaking sounds that indicate narrowed small air passages. They are usually heard on both inspiration and expiration.
Choice C is wrong because crackles are short, high-pitched popping sounds that indicate fluid or inflammation in the alveoli. They are usually heard on inspiration.
Choice D is wrong because pleural friction rubs are creaking or grating sounds that indicate inflammation of the pleura. They are usually heard on both inspiration and expiration and do not change with coughing.
Correct Answer is B
Explanation
The client on Digitalis has a low potassium level of 3.0 mEq/L, below the normal range of 3.5-5.0 mEq/L. Low potassium levels can increase the risk of digitalis toxicity, which can cause nausea, abdominal discomfort, visual changes, and cardiac arrhythmias.
The nurse would instruct the client to eat foods high in potassium, such as cantaloupe, to prevent or correct hypokalemia.
Choice A. Asparagus is wrong because asparagus is a low-potassium food that contains only 202 mg of potassium per cup.
Eating asparagus would not help to raise the client’s potassium level.
Choice C. Blackberries are wrong because blackberries are also a low-potassium food that contains only 233 mg of potassium per cup.
Eating blackberries would not help to raise the client’s potassium level.
Choice D. Cucumbers is wrong because cucumbers are a very low-potassium food that contains only 76 mg of potassium per cup.
Eating cucumbers would not help to raise the client’s potassium level and may even lower it further.
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