a client complaining of chest pain is prescribed an intravenous infusion of nitroglycerin nitro bid after the infusion is initiated the occurrence of
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Nursing Elites

NCLEX-PN

Kaplan NCLEX Question of The Day

1. A client complaining of chest pain is prescribed an intravenous infusion of nitroglycerin (Nitro-Bid). After the infusion is initiated, the occurrence of which symptom warrants the nurse discontinuing an intravenous infusion of nitroglycerin?

Correct answer: D

Rationale: The correct answer is 'Cool clammy skin.' This assessment finding indicates decreased cardiac output that could result from excessive vasodilation. Cool clammy skin is a sign of poor perfusion, suggesting that the blood pressure might be dropping too low. Discontinuing the nitroglycerin infusion is crucial to prevent further complications. Choice A, 'Frontal headache,' is a common side effect of nitroglycerin but not a reason to discontinue the infusion unless severe or persistent. Choice B, 'Orthostatic hypotension,' may occur as a side effect of nitroglycerin but does not necessarily warrant discontinuation unless severe. Choice C, 'Decrease in intensity of chest pain,' is actually an expected therapeutic response to nitroglycerin and indicates improved myocardial perfusion, so it is not a reason to stop the infusion.

2. While undergoing hemodialysis, the client becomes restless and tells the nurse he has a headache and feels nauseous. Which of the following complications does the nurse suspect?

Correct answer: C

Rationale: In this scenario, the client undergoing hemodialysis is experiencing symptoms like restlessness, a headache, and nausea. These symptoms are indicative of an air embolus, a serious complication that can occur during hemodialysis. Air embolus happens when air enters the bloodstream and can lead to symptoms like restlessness, a headache, and nausea. It is crucial for the nurse to suspect and address this complication promptly to prevent further harm to the client. Choices A and D (Infection) are less likely in this case, as the symptoms presented are more suggestive of an air embolus rather than an infection. Choice B (Disequilibrium syndrome) is also less likely as the symptoms described are not typical of this syndrome. Therefore, the correct answer is C: Air embolus.

3. In conducting a community health fair for a group of middle-aged citizens, which statement should the nurse emphasize in reducing the risk of coronary heart disease?

Correct answer: B

Rationale: Engaging in an aerobic exercise class every day is crucial in reducing the risk of coronary heart disease. Aerobic exercises help keep the heart in shape, lower blood pressure, and improve cholesterol levels. It is recommended to participate in at least 150 minutes of moderate-intensity aerobic exercise per week, which can be achieved by engaging in aerobic exercise daily. Choice A has been corrected to emphasize the frequency required to significantly reduce the risk of coronary heart disease. Choice C has been modified to suggest moderation in alcohol intake, as excessive alcohol consumption is harmful. Choice D is also incorrect as a balanced diet, not specifically high-protein, high-fat, is recommended to reduce the risk of coronary heart disease and maintain a healthy weight.

4. The client is admitted with a period of unobserved loss of consciousness and now has an EEG scheduled this morning. What should the nurse implement?

Correct answer: C

Rationale: Prior to an EEG, it is essential for the client to eat to prevent a drop in blood sugar levels. The nurse should hold sedatives but allow the client to have breakfast and administer other necessary medications. Holding sedatives is crucial to ensure accurate EEG results, while providing breakfast helps maintain stable blood sugar levels. Administering other medications, excluding sedatives, is important for the client's overall care. Choices A, C, and D are incorrect because keeping the client NPO and holding medications, administering medications but holding anticonvulsants, and giving additional fluids and caffeine are not appropriate actions before an EEG.

5. The nurse teaching about preventable diseases should emphasize the importance of getting the following vaccines:

Correct answer: D

Rationale: Vaccines are one of the most effective methods of preventing and controlling certain communicable diseases. The smallpox vaccine is not currently in use because the smallpox virus has been declared eradicated from the world's population. Diseases such as polio, diphtheria, pertussis, and measles are mostly controlled by routine childhood immunization. They have not, however, been eradicated, so children need to be immunized against these diseases. Choices A, B, and C contain vaccines that do not protect against preventable diseases like polio, pertussis, and measles. Therefore, the correct choice is D.

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