A male client reports to the on-call clinic nurse that he took tadalafil 10 mg by mouth two hours ago and his skin now feels flushed. He reports a history of stable angina, but denies experiencing any current or recent chest pain. Which action should the nurse take?
Advise the client to place one nitroglycerin tablet under his tongue as a precaution.
Tell the client to have someone bring him to an emergency department immediately.
Instruct the client to increase his intake of oral fluids until the skin flushing is relieved.
Reassure the client that skin flushing is a common side effect of the medication.
The Correct Answer is D
Choice A: Advising the client to place one nitroglycerin tablet under his tongue as a precaution is a dangerous action for the nurse, as this can cause severe hypotension and cardiovascular collapse due to the interaction between tadalafil and nitroglycerin. This is a contraindicated choice.
Choice B: Telling the client to have someone bring him to an emergency department immediately is an unnecessary action for the nurse, as there is no evidence of any serious adverse reaction or complication from tadalafil. This is an overreaction choice.
Choice C: Instructing the client to increase his intake of oral fluids until the skin flushing is relieved is not an appropriate action for the nurse, as this does not address the cause of the flushing, which is vasodilation due to tadalafil. This is a distractor choice.
Choice D: Reassuring the client that skin flushing is a common side effect of the medication is an appropriate action for the nurse, as this can calm the client and educate him about the expected effects of tadalafil. Therefore, this is the correct choice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: When the client has ankle edema is not the most important time for the nurse to assess DTRs, as this is a common finding in pregnancy and does not indicate a neurological or vascular problem. This is a distractor choice.
Choice B: Within the first trimester of pregnancy is not the most important time for the nurse to assess DTRs, as this is a routine assessment that can be done at any time during pregnancy and does not reflect any specific risk or complication. This is another distractor choice.
Choice C: If the client has an elevated blood pressure is the most important time for the nurse to assess DTRs, as this can indicate preeclampsia, a serious condition that can cause seizures, stroke, and organ damage. DTRs can help detect hyperreflexia, which is a sign of increased intracranial pressure and impending eclampsia. Therefore, this is the correct choice.
Choice D: During admission to labor and delivery is not the most important time for the nurse to assess DTRs, as this is a standard assessment that can be done at any stage of labor and does not signify any urgent or emergent situation. This is another distractor choice.
Correct Answer is C
Explanation
Choice A reason: Providing pain medication to increase the client's tolerance of labor pains is not a specific intervention for the second stage of labor. Pain medication is a drug that relieves pain by blocking pain signals or reducing inflammation. Pain medication can be given during any stage of labor, depending on the client's preference and condition. However, pain medication may have side effects such as sedation, nausea, or respiratory depression, and may affect the fetal heart rate or the progress of labor.
Choice B reason: Assessing the fetal heart rate and pattern for signs of fetal distress is not a particular intervention for the second stage of labor. Fetal heart rate and pattern are indicators of fetal well-being and oxygenation. Fetal heart rate and pattern should be monitored throughout labor, especially during contractions, to detect any abnormalities or complications such as bradycardia, tachycardia, or decelerations.
Choice D reason: Monitoring effects of oxytocin administration to help achieve cervical dilation is not a relevant intervention for the second stage of labor. Oxytocin is a hormone that stimulates uterine contractions and cervical dilation. Oxytocin can be administered during labor to augment or induce labor, especially if there is prolonged or dysfunctional labor. However, oxytocin is not needed in the second stage of labor, when the cervix is already fully dilated and the focus is on pushing and delivering the baby.
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