A client arrives to the emergency department with chest pain after taking sildenafil. Based on the client's history, which medication should the nurse withhold?
Aspirin.
Nitroglycerin.
Morphine.
Heparin.
The Correct Answer is B
Rationale
A. Aspirin is commonly used in the emergency setting for chest pain suspected to be due to acute coronary syndrome (ACS), which includes conditions like myocardial infarction (heart attack). It works by reducing blood clotting and can help alleviate symptoms in some cases. It is typically safe to administer aspirin
B. Sildenafil can interact with nitrates, such as nitroglycerin, and result in a significant drop in blood pressure. Therefore, the nurse should withhold nitroglycerin to prevent potential adverse effects.
C. Morphine is a potent opioid pain medication used in the emergency department for severe pain relief, including chest pain associated with suspected myocardial infarction. It can help reduce pain and anxiety in acute coronary syndromes. It has no significant interaction with sildenafil.
D. Heparin is an anticoagulant medication used to prevent blood clotting. It is often administered in the hospital setting for various indications, such as deep vein thrombosis, pulmonary embolism, or in some cases of acute coronary syndromes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale
A. Measuring vital signs, including respiratory rate, heart rate, blood pressure, and oxygen saturation, is important to assess the client's overall status and to determine the severity of the dyspnea. Vital signs provide essential information to guide further interventions. While important, this action may not directly alleviate the client's immediate distress from dyspnea.
B. Placing the client in a high Fowler's position (sitting upright with the head of the bed elevated to 90 degrees) helps to maximize chest expansion and improve lung ventilation. This position can relieve dyspnea by reducing pressure on the diaphragm and improving lung compliance. It is a simple and effective intervention for clients experiencing respiratory distress.
C. While deep breathing exercises are beneficial for promoting lung expansion and improving respiratory function, they may not be appropriate as the first action when the client is already dyspneic. The priority
should be to position the client to alleviate immediate breathing difficulty before initiating exercises that require active participation.
D. Auscultating breath sounds is important for assessing lung function and detecting any abnormalities such as adventitious sounds (e.g., crackles, wheezes). However, this action is secondary to placing the client in a high Fowler's position to relieve dyspnea. Auscultation can be performed after the client's breathing has stabilized.
Correct Answer is B
Explanation
Rationale
A. JVD is typically an indicator of increased central venous pressure and can be associated with heart failure or fluid overload. In this scenario, flat JVD suggests decreased venous return, which may exacerbate the client's hypotension. While important, it may not be the most immediate concern compared to other options.
B. Changes in consciousness, such as confusion, disorientation, or loss of consciousness, are critical signs that indicate poor cerebral perfusion. In this case, the rapid ventricular rate and possibly inadequate cardiac output may not be meeting cerebral perfusion needs, leading to altered mental status. This finding requires urgent attention to prevent further deterioration.
C. Nausea and vomiting can indicate inadequate perfusion to the gastrointestinal tract due to hypotension or impaired cardiac output. While important to assess for fluid and electrolyte balance, it is less urgent compared to potential changes in mental status or perfusion to vital organs.
D. A sudden onset headache can be indicative of various issues, including hypertension, cerebral ischemia, or intracranial hemorrhage. However, in the context of atrial fibrillation with rapid ventricular response and hypotension, other neurological signs such as altered mental status or focal neurological deficits would typically be more concerning.
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