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. The chemotherapeutic agent 5-fluorouracil (5-FU) is ordered for a client as an adjunct measure to surgery. Which statement about chemotherapy is true?

Correct answer: B

Rationale: The correct answer is that chemotherapy is a systemic treatment affecting both tumor and normal cells. 5-FU, as an antimetabolic drug, inhibits DNA synthesis and interferes with cell replication systemically. It affects all rapidly growing cells, including malignant and normal ones. This drug is used as adjuvant therapy for various cancers. Choice A is incorrect because chemotherapy affects both tumor and normal cells, not just tumor cells. Choice C is incorrect as chemotherapy has been proven effective in treating cancer. Choice D is incorrect because chemotherapy often causes side effects like bone marrow depression, anorexia, stomatitis, nausea, and vomiting.

3. How can the nurse promote relief of muscle pain, spasms, and tension?

Correct answer: C

Rationale: To promote relief of muscle pain, spasms, and tension, the nurse should consider applying heat, cold, pressure, or vibration to the painful area. These interventions can help alleviate pain associated with muscle tension, pain, or spasms. Choice A is incorrect because encouraging the client to continue their activities as usual may exacerbate the pain. Choice B is incorrect as immobilizing the client may not address the underlying issue and could potentially lead to further complications. Choice D is also incorrect because while pain medication can be used, it is not the first-line treatment for muscle pain, spasms, and tension.

4. The client is preparing to undergo a total hysterectomy for advanced cervical cancer. The client is crying and says that she wants to have more children and is unsure if she should have the procedure. What should the nurse do?

Correct answer: A

Rationale: In this situation, the most appropriate action for the nurse is to allow the client to express her fears and concerns openly. By encouraging her to talk more with her physician, the nurse is promoting effective communication and ensuring that the client receives adequate information to make an informed decision. Option A is correct because it acknowledges the client's emotions and empowers her to seek clarification and support from her healthcare provider. Options B and C do not address the client's emotional needs or provide a solution to her concerns regarding fertility. Option D is not appropriate as it does not prioritize the client's emotional well-being and delays necessary medical treatment for advanced cervical cancer.

5. A 46-year-old has returned from a heart catheterization and wants to get up to start walking 3 hours after the procedure. The nurse should:

Correct answer: A

Rationale: The correct answer is to tell the patient to remain with the leg straight for at least another hour after a heart catheterization before starting ambulation. This period allows for proper healing and reduces the risk of complications such as bleeding or hematoma formation at the catheter insertion site. Starting ambulation too soon can disrupt the healing process and lead to adverse events. Choice B is incorrect because limited ambulation should not be initiated shortly after the procedure as it may increase the risk of complications. Choice C is incorrect as physical therapy consultation is not typically necessary for initial ambulation post-heart catheterization; this can be managed by nursing staff. Choice D is incorrect as keeping the leg straight for 6 hours is excessive and unnecessary, potentially leading to complications such as deep vein thrombosis due to prolonged immobility.

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