A male client reports to the on-call 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?
Instruct the client to increase his intake of oral fluids until the skin flushing is relieved.
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.
Reassure the client that skin flushing is a common side effect of the medication.
The Correct Answer is D
Choice A: 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 B: 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 C: 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 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 D
Explanation
The correct answer is: c. Leave the light on in the room at night.
Choice A: Replace the IV catheter with a smaller gauge
Replacing the IV catheter with a smaller gauge is not directly addressing the issue of the client’s confusion and agitation. While a smaller gauge might be less irritating, it does not solve the problem of the client picking at the IV site. The pinkness at the IV site suggests mild irritation or early signs of phlebitis, which can be managed by monitoring and ensuring proper securement and care of the IV site.
Choice B: Apply soft bilateral wrist restraints
Applying wrist restraints should be a last resort due to the potential for causing distress, agitation, and physical harm to the patient. Restraints can lead to negative outcomes such as decreased circulation, pressure ulcers, and increased agitation, especially in patients with dementia. It is generally recommended to use less restrictive measures first.
Choice C: Leave the light on in the room at night
Leaving the light on in the room at night (C) can help reduce confusion and agitation in dementia patients, a phenomenon known as sundowning. However, it does not address the immediate issue of the non-occlusive dressing and the pink IV insertion site.
Choice D: Redress the abdominal incision
Given the situation, the most appropriate intervention would be to redress the abdominal incision (D). This is because the dressing is no longer occlusive, which can increase the risk of infection. Ensuring the dressing is secure and clean is crucial for the patient's safety.
Correct Answer is A
Explanation
Choice A reason: This is the correct answer.According to the rule of nines, each leg accounts for 18% of the total body surface area, and the anterior surface of each leg accounts for half of that, or 9%. Therefore, the patient has partial-thickness burns on 9% + 9% = 18% of the body surface area.
Choice B reason: This is incorrect. This would be the case if the patient had partial-thickness burns on the anterior and posterior surfaces of both legs, as well as the head and neck, which is not given in the question.
Choice C reason: This is incorrect. This would be the case if the patient had partial-thickness burns on the anterior surface of only one leg, which is not given in the question.
Choice D reason: This is incorrect. This would be the case if the patient had partial-thickness burns on the anterior and posterior surfaces of both legs, which is not given in the question.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today