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The nurse responds to the call light of a client who has a history of angina pectoris. He tells the nurse that he has just taken a nitroglycerin tablet sublingually for anginal pain. What action should the nurse take next?
- A. If the pain does not subside within five minutes, place a second tablet under his tongue
- B. Position him with head lower than feet
- C. Administer a narcotic as needed (PRN) for pain if he still has pain in 10 minutes
- D. Call his physician and alert the code team for possible intervention
Correct Answer: A
Rationale: If anginal pain persists five minutes after the first nitroglycerin tablet, a second tablet should be administered, with up to three doses at five-minute intervals. Positioning with head lower than feet, narcotics, or calling the physician are not the immediate next steps.
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Which assessment finding should signal the nurse to withhold applying the client's nitroglycerin patch and notify the physician?
- A. The pressure of 99.8°F (37.6°C)
- B. Respiratory rate of 24 breaths/minute at rest
- C. Apical heart rate of 90 beats/minute
- D. Blood pressure of 94/62 mm Hg
Correct Answer: D
Rationale: A blood pressure of 94/62 mm Hg indicates hypotension, a contraindication for nitroglycerin, which can further lower blood pressure.
Having heard the observer's comment, which statement by the nurse would be most helpful for an untrained individual to remember if a trained individual is not present?
- A. An untrained person can always stay with the victim until help arrives.
- B. Do not worry about compressions; just breathe regularly in the mouth.
- C. Begin chest compressions in the center of the chest pressing down 2 inches (5 cm).
- D. Place the client flat and elevate the feet to promote circulation.
Correct Answer: C
Rationale: Untrained individuals can perform compression-only CPR, pressing 2 inches deep at 100-120 per minute.
Which value should the nurse report immediately to the physician?
- A. Sodium: 137 mEq/L
- B. Potassium: 2.5 mEq/L
- C. Chloride: 97 mEq/L
- D. Bicarbonate: 25 mEq/L
Correct Answer: B
Rationale: Potassium of 2.5 mEq/L (hypokalemia) is critical, especially with diuretics, risking arrhythmias.
The client tells the nurse of being extremely frightened. What is the most appropriate action for the nurse to take at this time?
- A. Stay with the client.
- B. Explain the procedures.
- C. Tell the client it will be fine.
- D. Record the collected data.
Correct Answer: A
Rationale: Staying with the client provides emotional support, reducing fear during a crisis.
What is the best explanation for the drug therapy in this situation?
- A. Aspirin tends to relieve chest pain.
- B. Aspirin tends to prevent blood clots.
- C. Aspirin tends to lower the blood pressure.
- D. Aspirin tendsmedi tends to dilate the coronary arteries.
Correct Answer: B
Rationale: Aspirin's antiplatelet effect prevents thrombus formation at the PTCA site, reducing the risk of re-occlusion.