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 A
Explanation
Choice A: Moderate amount of foul-smelling lochia. This is the most indicative finding of a postpartum infection, as it suggests that the client has endometritis, which is an inflammation of the uterine lining. Endometritis is a common cause of maternal morbidity and mortality, and requires prompt antibiotic treatment.
Choice B: Blood pressure of 122/74 mm Hg. This is a normal blood pressure for a postpartum client, and does not indicate an infection. The reference range for blood pressure is 90/60 to 140/90 mm Hg.
Choice C: Oral temperature of 100.2°F (37.9°C.. This is a slightly elevated temperature for a postpartum client, but it does not necessarily indicate an infection. The reference range for oral temperature is 97.6 to 99.6°F (36.4 to 37.6°C.. A mild fever may occur in the first 24 hours after delivery due to dehydration or hormonal changes.
Choice D: White blood cell count of 19,000/mm³ (19 x 10⁹/L). This is a high white blood cell count for a postpartum client, but it does not indicate an infection. The reference range for white blood cell count is 5,000 to 10,000/mm³ (5 to 10 x 10⁹/L). A leukocytosis may occur in the first few days after delivery due to stress or tissue injury.
Correct Answer is D
Explanation
Choice A reason: Marking an outline of the "olive-shaped" mass in the right epigastric area is not a priority nursing action. The mass is caused by hypertrophy of the pyloric sphincter, which obstructs gastric emptying and causes projectile vomiting. The mass may not be palpable in all cases.
Choice B reason: Instructing parents regarding care of the incisional area is a post-operative nursing action, not a pre-operative one. The parents will need to learn how to keep the incision clean and dry, monitor for signs of infection, and administer pain medication as prescribed.
Choice C reason: Monitoring amount of intake and infant's response to feedings is important, but not the highest priority. The infant may have difficulty feeding due to nausea, vomiting, and abdominal pain.
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