Nokea
A client is prescribed nitrate therapy as treatment for angina. On a follow-up visit to the clinic, the client tells the nurse that he gets dizzy and weak when he takes the medication. The nurse would identify which nursing diagnosis as most likely?
- A. Risk for Injury
- B. Risk for Infection
- C. Deficient Fluid Volume
- D. Acute Pain
Correct Answer: A
Rationale: The client is at risk for injury because of his complaints of dizziness and weakness. There is no indication that the client is experiencing an infection or has a fluid volume deficit. Complaints of pain would lead to a nursing diagnosis of Acute Pain.
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A client is being discharged after being treated with nitroglycerin for angina. Which of the following instructions should the nurse include in the teaching plan for the client?
- A. Store the nitroglycerin capsules in a plastic container.
- B. Place the nitroglycerin capsules along with other tablets.
- C. Recap the container tightly after taking out the capsules.
- D. Do not store nitroglycerin in a dark container.
Correct Answer: C
Rationale: The nurse should instruct the client to recap the container tightly after taking out the nitroglycerin capsule. This is to ensure that the potency of nitroglycerin is not lost on exposure to air. Nitroglycerin should be stored in a dark container and protected from direct light exposure.
A nurse is preparing to administer nitroglycerin intravenously. Which of the following would be important for the nurse to keep in mind? Select all that apply.
- A. Using glass bottles
- B. Using non-polyvinyl chloride (PVC) infusion sets
- C. Administering the drug as an IV bolus
- D. Diluting the drug with normal saline
- E. Using a gravity flow rate of infusion
Correct Answer: A,B,D
Rationale: When administering IV nitroglycerin, the nurse should dilute it with normal saline or 5% dextrose in water, administer the drug by continuous infusion using an infusion pump for accuracy, and use glass IV bottles and non-PVC infusion sets. The dose is regulated based on client response.
A client arrives at the urgent care center complaining of chest pain and is diagnosed with angina pectoris. Which of the following would the nurse expect to be prescribed?
- A. Nicardipine
- B. Hydralazine
- C. Minoxidil
- D. Nimodipine
Correct Answer: A
Rationale: Nicardipine is the drug used in the treatment of angina. Nicardipine is a calcium channel blocker used as an antianginal drug. Hydralazine and minoxidil are vasodilators primarily used to treat hypertension. Nimodipine is a calcium channel blocker used to treat subarachnoid hemorrhage.
When instructing the client on how to use the prescribed nitroglycerin ointment, the nurse would tell the client to use which of the following to determine the amount?
- A. A teaspoon
- B. Length of a finger
- C. Paper applicator
- D. The size of the previous dose
Correct Answer: C
Rationale: The topical ointment is supplied with a paper applicator to determine the amount of drug to be used. No other method is appropriate.
When applying nitroglycerin ointment, which of the following would be appropriate? Select all that apply.
- A. Wear plastic disposable gloves.
- B. Apply entire tube of ointment to client's skin.
- C. Use the same application site each time ointment is applied.
- D. Cleanse the area of skin before application
- E. Use the upper arms and legs for application
Correct Answer: A,D,E
Rationale: The nurse should wear plastic gloves while administering ointment and use application paper to measure and apply ointment to the client's chest, abdomen, or upper arms and legs. The application site should be rotated and cleansed with each application.