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

Chicken breast, green beans, and a glass of milk. This is because chicken breast is a good source of protein, which is essential for wound healing. Green beans are rich in vitamin C, which helps with collagen synthesis and immune function. Milk is a good source of calcium and vitamin D, which are important for bone health and healing.

Choice A is wrong because cheese pizza and french fries are high in fat and sodium, which can increase inflammation and delay wound healing. Orange juice is high in sugar, which can also impair wound healing and increase the risk of infection.

Choice B is wrong because cheeseburger and potato chips are also high in fat and sodium, and have similar effects as choice A. Soda is also high in sugar and can cause dehydration, which can slow down wound healing.

Choice D is wrong because spaghetti and meatballs are high in refined carbohydrates, which can spike blood sugar levels and impair wound healing.

A roll is also a refined carbohydrate and does not provide much fiber or nutrients. Chocolate pudding is high in sugar and fat, and can also worsen wound healing.

A. Isolation or barrier procedures. B. Standard precautions. C. Hand hygiene techniques. D. Routine cleaning of client rooms.

Correct Answer is C

Explanation

Hand hygiene techniques are the first line of defense in medical asepsis because they prevent the transmission of microorganisms from one person or object to another. Hand hygiene techniques include washing hands with soap and water or using an alcohol-based handrub.

Choice A is wrong because isolation or barrier procedures are not the first line of defense in medical asepsis, but rather a way of preventing the spread of infection to other patients or health care workers when a patient has a known or suspected infection.

Choice b is wrong because the nature of detergent used on the unit is not the first line of defense in medical asepsis, but rather a factor that affects the effectiveness of cleaning and disinfection of surfaces and equipment.

Choice D is wrong because the ventilation system type is not the first line of defense in medical asepsis, but rather a factor that affects the quality of air and the risk of airborne transmission of microorganisms.

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Which nursing action is most important after administering nitroglycerin sublingually?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is learning about diet choices that will increase wound healing after a total knee replacement. What diet selection would indicate that the client understands the correct foods to choose for that outcome to happen?

Correct Answer is C

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A nurse who serves on an infection control committee is assessing the adequacy of environmental controls against infection. What does the nurse know to be the first line of defense in medical asepsis?

Correct Answer is C

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