Nokea
Prior to administering an antianginal drug, the nurse should assess which of the following? Select all that apply.
- A. Pain
- B. Physical appearance
- C. Lung sounds
- D. Heart sounds
- E. Vital signs
Correct Answer: A,B,C,E
Rationale: Before administering an antianginal agent, the nurse would assess the client's pain, history of medication allergies and disease processes, physical appearance, and lungs for adventitious sounds and obtain a baseline electrocardiogram and vital signs.
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Which of the following does the nurse need to include as part of the physical assessment of a client with anginal pain? Select all that apply.
- A. Blood pressure
- B. Apical pulse
- C. Oxygen saturation
- D. Radial pulse
- E. Respiratory rate
Correct Answer: A,B,D,E
Rationale: The nurse's physical assessment of a client with angina should include blood pressure, respiratory rate, and apical and radial pulses. The physical assessment may also include weight, inspection of the extremities for edema, and auscultation of the lungs, depending on the type of heart failure.
A nurse is teaching a client who is prescribed nitrate therapy about adverse reactions. When discussing headaches associated with nitrates, which of the following would the nurse include? Select all that apply.
- A. Headaches should decrease with continued therapy.
- B. Headaches may be relieved with the use of aspirin or acetaminophen.
- C. Headaches should be avoided by altering the dosage schedule.
- D. Headaches are a serious adverse reaction and should be reported immediately.
- E. Headaches may be a marker of the drug's effectiveness.
Correct Answer: A,B,E
Rationale: Headaches are a common adverse reaction of nitrates but should decrease with continued therapy. Headaches should be reported if they become severe or persist. Headaches may be a marker of the nitrate's effectiveness, and clients should not alter the dosing schedule to avoid headaches. Headaches may be treated with acetaminophen or aspirin.
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 nurse instructs a client who is taking oral nitrates to store the drug in which manner? Select all that apply.
- A. In its original container
- B. With the container lid tightly sealed
- C. With other medications in the container
- D. In a plastic pill box so doses are not missed
- E. Away from light exposure
Correct Answer: A,B,E
Rationale: The proper storage of oral nitroglycerin includes keeping tablets and capsules in their original container, never mixing oral nitroglycerin with other drugs in a container, never storing oral nitroglycerin in a plastic container, keeping the drug away from light, and always replacing the container tightly and as soon as the drug is removed.
A client receiving amlodipine for angina is complaining of dizziness. Which of the following interventions should the nurse implement to help alleviate the condition?
- A. Apply a cold cloth over the forehead.
- B. Instruct the client to lie down.
- C. Instruct the client to drink more water.
- D. Reduce the dosage of amlodipine.
Correct Answer: B
Rationale: Dizziness is a common central nervous system adverse effect seen with calcium channel blocker use. The nurse should instruct the client to lie down until the dizziness passes. Applying a cold cloth over the forehead will not relieve the dizziness.