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The nurse is assisting in the care of a client with a history of angina pectoris who is receiving nitroglycerin patches. Which instruction should the nurse reinforce with the client?
- A. Apply the patch to a different site each time.
- B. Remove the patch at night to prevent tolerance.
- C. Use more than one patch if chest pain occurs.
- D. Shower with caution while wearing the patch.
Correct Answer: B
Rationale: Removing the nitroglycerin patch at night is essential to prevent the development of tolerance. Tolerance can occur when the body gets used to a constant level of the medication, reducing its effectiveness. By removing the patch at night, the client has a drug-free period, which helps prevent tolerance and maintains the effectiveness of the nitroglycerin for angina relief.
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A client who had a myocardial infarction (MI) two days ago reports chest pain radiating to the left arm. What should the nurse do immediately?
- A. Administer morphine
- B. Obtain an electrocardiogram (ECG)
- C. Apply oxygen via nasal cannula
- D. Administer sublingual nitroglycerin
Correct Answer: B
Rationale: Obtaining an ECG is crucial in this situation because it helps in assessing for potential complications, such as a recurrent MI or ongoing ischemia. This diagnostic test provides valuable information to guide further interventions and treatment. Administering morphine, oxygen, or nitroglycerin may be necessary but obtaining an ECG takes precedence to evaluate the cardiac status and determine the appropriate course of action.
The nurse is caring for a client receiving anticoagulant therapy. Which instruction should the nurse reinforce with the client to prevent bleeding complications?
- A. Use a soft-bristle toothbrush and electric razor.
- B. Increase your intake of vitamin K-rich foods.
- C. Take aspirin if you have a headache.
- D. Avoid using ice packs for injuries.
Correct Answer: A
Rationale: The correct instruction to prevent bleeding complications in a client on anticoagulant therapy is to use a soft-bristle toothbrush and electric razor. These implements help reduce the risk of bleeding by being gentle on the skin and reducing the chances of cuts or abrasions that could lead to bleeding in individuals on anticoagulants.
The LPN/LVN is assisting in the care of a client with a diagnosis of heart failure who is receiving digoxin (Lanoxin). Which laboratory result should the nurse monitor closely?
- A. Serum sodium
- B. Serum potassium
- C. Serum calcium
- D. Serum glucose
Correct Answer: B
Rationale: The correct answer is serum potassium. Monitoring serum potassium levels is crucial when a client is receiving digoxin (Lanoxin) because low potassium levels can increase the risk of digoxin toxicity. Digoxin and low potassium levels can lead to serious cardiac complications, such as arrhythmias. Therefore, close monitoring of serum potassium is essential to prevent adverse effects and ensure the safe administration of digoxin in clients with heart failure.
A client with a history of myocardial infarction (MI) is being discharged with a prescription for nitroglycerin sublingual tablets. Which instruction should the nurse reinforce?
- A. Store the tablets in a cool, dry place away from light.
- B. Take a tablet every 5 minutes if chest pain occurs.
- C. Place the tablets under the tongue for sublingual absorption.
- D. Take the tablets without water for faster effect.
Correct Answer: A
Rationale: Nitroglycerin tablets are light and moisture-sensitive, so they should be stored in a cool, dry place away from light to maintain their effectiveness. Option B advises taking a tablet every 5 minutes, which may lead to overdose. Option C emphasizes the correct administration route for sublingual tablets. Option D is incorrect as water is not needed for the tablets to take effect.
The nurse is caring for a client with coronary artery disease (CAD) who reports chest pain. The nurse administers nitroglycerin as prescribed. What is the next priority action?
- A. Obtain a 12-lead ECG
- B. Monitor the client's blood pressure
- C. Notify the healthcare provider
- D. Administer a second dose of nitroglycerin
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.