a client taking nitroglycerin nitrostat for angina asks the nurse to explain possible side effects what should not be included in client teaching a client taking nitroglycerin nitrostat for angina asks the nurse to explain possible side effects what should not be included in client teaching
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Nursing Elites

ATI RN

Pharmacology ATI Proctored Exam 2023

1. A client taking nitroglycerin (Nitrostat) for angina asks the nurse to explain possible side effects. What should NOT be included in client teaching?

Correct answer: C

Rationale: Hyponatremia is not a common side effect associated with nitroglycerin use. Nitroglycerin typically causes side effects such as reflex tachycardia, dizziness, and hypotension due to its vasodilatory effects. Therefore, it is important for the nurse to educate the client about these potential side effects to promote understanding and appropriate management.

2. During a home visit to an older client living alone post-coronary artery bypass graft, what finding prompts the nurse to consider additional referrals?

Correct answer: B

Rationale: The presence of expired food in the refrigerator is concerning as it raises safety issues for the client and indicates potential financial constraints preventing them from buying fresh food. The nurse should consider referring the client to services like Meals on Wheels or other home-based food programs to address this issue and ensure the client's nutritional needs are met.

3. The nurse is most concerned about which of these findings in a client with systemic lupus erythematous?

Correct answer: Urine output of 20 mL/hour

Rationale:

4. A client is receiving heparin therapy. Which laboratory value should be monitored by the nurse to evaluate the effectiveness of the therapy?

Correct answer: B

Rationale: The activated partial thromboplastin time (aPTT) is specifically used to monitor the effectiveness of heparin therapy. It should be maintained at 1.5 to 2 times the normal level. Monitoring aPTT helps ensure that the therapeutic range of heparin is achieved to prevent clot formation while minimizing the risk of bleeding complications. Choice A (PT) is incorrect as it is used to monitor warfarin therapy, not heparin. Choice C (INR) is also incorrect as it is primarily used to monitor warfarin therapy. Choice D (Platelet count) is not directly related to monitoring the effectiveness of heparin therapy.

5. Which of the following is an example of a tertiary prevention strategy?

Correct answer: D

Rationale: The correct answer is D: Physical therapy for stroke rehabilitation. Tertiary prevention aims to prevent complications and manage existing conditions to improve the quality of life. Administering childhood vaccinations (A) is an example of primary prevention to prevent the onset of diseases. Chemotherapy for cancer treatment (B) is a form of secondary prevention focusing on early detection and treatment to stop the progression of the disease. Routine screening for hypertension (C) is also a form of secondary prevention to detect and treat hypertension early, preventing further complications.

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