A client newly diagnosed with angina pectoris has taken two sublingual nitroglycerin tablets for chest pain. The chest pain is relieved, but the client now reports a headache. The nurse interprets that this most likely represents which response?
An expected side effect of the medication
An allergic reaction to the nitroglycerin
A sign that the medication should not be used again
An indication of worsening cardiac condition
The Correct Answer is A
Choice A reason: A headache is a common and expected side effect of nitroglycerin. Nitroglycerin causes vasodilation, which can lead to increased blood flow to the head and result in headaches. It is important to inform the client that this is a known side effect and to manage it with appropriate measures, such as taking analgesics.
Choice B reason: An allergic reaction to nitroglycerin would typically present with symptoms such as rash, itching, swelling, or difficulty breathing. A headache alone does not indicate an allergic reaction.
Choice C reason: A headache does not mean the medication should not be used again. It is a common side effect, and the benefits of nitroglycerin in relieving chest pain usually outweigh the discomfort of the headache. The nurse should educate the client on managing the headache while continuing the medication.
Choice D reason: A headache is not an indication of a worsening cardiac condition. It is a common side effect of the vasodilatory effects of nitroglycerin.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Atropine is an anticholinergic medication that blocks the effects of the parasympathetic nervous system. One of its effects is relaxation of the smooth muscles in the bladder, which can lead to urinary retention. This occurs because the bladder's ability to contract is inhibited, making it difficult for the patient to void.
Choice B reason: Bradycardia is not an expected effect of atropine. In fact, atropine is often used to treat bradycardia by increasing heart rate. It works by blocking the vagus nerve's influence on the heart, which normally acts to slow the heart rate. Therefore, atropine would be expected to cause an increase in heart rate, not a decrease.
Choice C reason: Diarrhea is not a common effect of atropine. Atropine works by reducing the activity of the gastrointestinal tract, leading to a decrease in bowel movements and potentially causing constipation rather than diarrhea. Anticholinergic drugs like atropine reduce gastrointestinal motility, which can lead to a slower passage of food through the intestines.
Choice D reason: Vomiting is not typically associated with the administration of atropine. While nausea and vomiting can be side effects of many medications, atropine more commonly causes dry mouth, blurred vision, and constipation. The medication's action on the gastrointestinal tract tends to slow digestive processes rather than stimulate vomiting.
Correct Answer is B
Explanation
Choice A reason: Verifying the conductive gel pads is important but should be done before the command "CLEAR!" is given.
Choice B reason: Stepping away from the bed and ensuring others have done the same is crucial for safety. It prevents accidental electrical shock to anyone touching the patient or bed during defibrillation.
Choice C reason: Shutting off the intravenous infusion is not necessary during defibrillation. It does not pose a safety risk in this context.
Choice D reason: Shutting off the mechanical ventilator is not necessary during defibrillation and could compromise the patient's ventilation status.
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