Author Question: The nurse is reinforcing discharge instructions for the client newly diagnosed with angina. The ... (Read 71 times)

biggirl4568 · **on:** Jul 22, 2018

The nurse is reinforcing discharge instructions for the client newly diagnosed with angina.

The client says, My friend has angina, and he always carries nitroglycerine with him, but he uses it so rarely, he always jokes that it probably wouldn't even work because it's so old. The nurse explains the way to tell if nitroglycerine is still effective is: 1. If it resolves the chest pain, it's working; if not, it should be replaced.
2. If, when it's placed under the tongue, it produces a tingling sensation.
3. To look at the color of the pill; if it's still white, it's still good.
4. If it hasn't been exposed to air, it will last for five years.

Question 2

The nurse admits a client in the early stage of labor and asks if the membranes have ruptured. The client states, I don't know if my water broke or not. The nurse plans to call the physician, who will ask if membranes have ruptured.

The nurse will: 1. Quote the mother's response and tell the physician that status of membranes is unknown.
2. Assume membranes are intact, or the client would know they ruptured.
3. Perform a pelvic examination to determine if membranes are intact.
4. Perform a Nitrazine test of vaginal secretions for presence of amniotic fluid.

heinisk01 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

2
Rationale: Nitroglycerine, if still active, will cause a tingling sensation when placed sublingually because of the vasodilation it causes. For safety reasons, the medication should be discarded and replaced when it exceeds the expiration date on the label of the bottle.

Answer to Question 2

4
Rationale: A Nitrazine test will test positive if amniotic fluid is present in the vaginal secretions, allowing the nurse to relate that the client is unsure if membranes ruptured but the results of the Nitrazine test indicated either negative or positive.