Nokea
The nurse is reinforcing teaching with a client who has a new prescription for sublingual nitroglycerin. Which of the following statements by the client would indicate a correct understanding of the teaching?
- A. I am able to take nitroglycerin with my prescribed vardenafil
- B. I will stop taking nitroglycerin if I experience a headache or flushing
- C. I can keep a few nitroglycerin tablets in a plastic bag in case I need them while I am away from home
- D. I should take 1 nitroglycerin tablet every 5 minutes, up to 3 doses, if I am experiencing chest pain
Correct Answer: D
Rationale: Many clients lack knowledge about the proper administration, storage, and side effects of nitroglycerin (NTG). Client teaching can prevent many emergency department visits for chest pain caused by stable angina. Clients should be taught to take 1 tablet every 5 minutes, up to 3 doses. Emergency medical services should be called if pain does not improve or worsens 5 minutes after the first tablet is taken. Previously, clients were taught to call after the third dose was taken, but new evidence suggests this causes a significant delay in treatment
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A client with suspected foot osteomyelitis is scheduled for an MRI. Which client findings should the nurse report before the test? Select all that apply.
- A. Cardiac pacemaker
- B. Colostomy
- C. Retained metal foreign body in eye
- D. Total hip replacement
- E. Transdermal testosterone patch
Correct Answer: A,C,D
Rationale: Pacemakers, metal in the eye, and hip replacements pose MRI risks due to magnetic interference or heating. Colostomies and transdermal patches are not contraindicated for MRI.
When the nurse is caring for a client receiving a neuroleptic medication exhibiting torticollis and involuntary muscle movement, what is the priority nursing action?
- A. Have respiratory support equipment available
- B. Administer an antiemetic medication
- C. Monitor the client’s temperature closely
- D. Administer an antihistamine
Correct Answer: A
Rationale: Have respiratory support equipment available. These side effects could lead to respiratory failure, necessitating immediate respiratory support.
A client involved in a motor vehicle accident has a 4-inch laceration on her left lower leg. Which finding is consistent with an acute inflammatory reaction?
- A. Increased pain caused by the release of histamine
- B. Blanching of the skin proximal to the laceration
- C. A decrease in the white blood count
- D. Granulation of tissue at the edges of the laceration
Correct Answer: A
Rationale: Histamine release during acute inflammation causes pain and vasodilation. Blanching is not typical, white blood count increases, and granulation occurs later.
The nurse is caring for assigned clients. The nurse should first check the client with
- A. sickle cell disease who has new onset pain rated as 9 on a scale of 0-10
- B. pneumonia who has a temperature of 100.6°F (38.1°C) and is receiving IV antibiotics
- C. Graves’ disease who has a heart rate of 110/min and a blood pressure of 122/85 mm Hg
- D. diabetes mellitus who has an elevated serum glucose level and is requesting insulin lispro prior to a meal
Correct Answer: A
Rationale: Severe pain (9/10) in sickle cell disease indicates a possible vaso-occlusive crisis, a medical emergency requiring immediate assessment. Fever, tachycardia, and hyperglycemia are less urgent.
The nurse is caring for an adult who has atrial fibrillation and osteoporosis. Atenolol is prescribed. The nurse should expect that this medication was prescribed to:
- A. decrease elevated blood pressure.
- B. decrease inflammation.
- C. relieve pain.
- D. slow the heart rate.
Correct Answer: D
Rationale: Atenolol, a beta-blocker, is used in atrial fibrillation to control heart rate, reducing rapid ventricular response.