Which patient statement indicates that the nurse's teaching about sublingual nitroglycerin (Nitrostat) has been effective?.
"I can expect nausea as a side effect of nitroglycerin.”.
"I will store the medication in a well-lit room.”.
"I will call an ambulance if I have pain 5 minutes after taking nitroglycerin.”.
"I should only take nitroglycerin when I have chest pain.”.
The Correct Answer is C
Choice A rationale:
Nitroglycerin can cause side effects such as headache and dizziness, but nausea is not a common side effect.
Choice B rationale:
Nitroglycerin should be stored in a dark, cool place, not in a well-lit room.
Choice C rationale:
This is the correct answer. If chest pain is not relieved 5 minutes after taking nitroglycerin, it is recommended to call an ambulance.
Choice D rationale:
While nitroglycerin is taken when chest pain occurs, it can also be taken prior to activities that might cause chest pain.
So, the correct answer is Choice C, after analyzing all choices.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Pericarditis is an inflammation of the pericardium and would not directly cause an S4 heart sound.
Choice B rationale:
Arterial obstruction or aneurysm would cause changes in blood flow, but not specifically an S4 heart sound.
Choice C rationale:
An S4 heart sound is an extra sound that is heard late in diastole just before S1. It occurs due to resistance to blood flow in an enlarged ventricle, often due to forceful atrial contraction to overcome ventricular resistance.
Choice D rationale:
An infectious valvular disorder could cause a variety of heart sounds, but not specifically an S42.
So, the correct answer is C, after analyzing all choices.
Correct Answer is ["C","E","G","H"]
Explanation
Choice A rationale:
The apical pulse rate increased from 90/min to 112/min, which is still within the normal range (60-100 beats per minute). Therefore, it’s not a critical change.
Choice B rationale:
The adolescent’s position, supine with legs straight, is the recommended position after cardiac catheterization to prevent bleeding from the femoral artery puncture site.
Choice C rationale:
The pulses of the right extremity decreased to 2+, indicating reduced blood flow. This is a critical finding and should be reported.
Choice D rationale:
The pain increased from 0 to 2 on a scale of 0 to 10. While any increase in pain should be monitored, a score of 2 is not typically considered severe.
Choice E rationale:
The pressure dressing became saturated with bloody drainage, indicating possible bleeding. This is a critical finding and should be reported.
Choice F rationale:
The respiratory rate increased from 16/min to 18/min, which is still within the normal range (12-20 breaths per minute). Therefore, it’s not a critical change.
Choice G rationale:
The blood pressure decreased from 120/76 mm Hg to 100/52 mm Hg. A significant drop in blood pressure can indicate blood loss or shock. This is a critical finding and should be reported.
Choice H rationale:
The right lower extremity became cool and pale, indicating reduced blood flow. This is a critical finding and should be reported.
So, the correct answer is Choice C, E, G, H, after analyzing all choices. .
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