A nurse administered nitroglycerin sublingually to a client who has angina pectoris and experienced chest pain.
The client states that his chest pain is relieved but now he has a headache.
Which of the following responses by the nurse is appropriate?

"A headache indicates tolerance to the medication.”.

"It sounds as if you are allergic to this medication.”.

"A headache is a common adverse effect of this medication, but it will probably occur less often over time.”.

"Your headache is probably a result of anxiety about the chest pain.”.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Tolerance to nitroglycerin is not indicated by the presence of a headache. Nitroglycerin is a vasodilator used to relieve angina, and headaches can be a common side effect.

Choice B rationale:

Allergic reactions to nitroglycerin are rare, and a headache is not a typical symptom of an allergy to this medication.

Choice C rationale:

"A headache is a common adverse effect of this medication, but it will probably occur less often over time.”. This is the correct response. Nitroglycerin commonly causes headaches due to its vasodilatory effects. Patients often experience this side effect initially, but it tends to improve or occur less frequently with continued use. The nurse should educate the client about this and reassure them that the headaches should diminish over time.

Choice D rationale:

Anxiety may exacerbate chest pain, but it is not the likely cause of the headache. It is important to address the headache as a potential side effect of the medication.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale:
Chloride 99 mEq/L. Rationale: A chloride level of 99 mEq/L is within the normal range, which is typically around 96-106 mEq/L. There is no need to report this value to the provider as it is not indicative of a significant abnormality.
Choice C rationale:
Magnesium 1.9 mg/dL. Rationale: A magnesium level of 1.9 mg/dL is within the normal range, which is generally about 1.5-2.5 mg/dL. This value is not indicative of a significant abnormality and does not require immediate reporting to the provider.
Choice D rationale:
Potassium 3.6 mEq/L. Rationale: A potassium level of 3.6 mEq/L is within the normal range, which is typically around 3.5-5.0 mEq/L. While it's on the lower side of the normal range, it is not low enough to warrant immediate reporting to the provider. However, the nurse should continue to monitor the client's potassium levels and address any potential issues if they persist or worsen.
Choice B rationale:
Sodium 126 mEq/L. Rationale: A sodium level of 126 mEq/L is below the normal range, which is typically around 135-145 mEq/L. Hyponatremia, or low sodium levels, can be a serious condition that can lead to neurological symptoms and other complications. Therefore, the nurse should promptly report this finding to the provider so that appropriate interventions can be initiated.

A. Withhold the digoxin dose for decreased heart rate. B. Administer digoxin 0.25 mg. C. Administer digoxin 0.125 mg. D. Withhold the digoxin dose for elevated BP. .

Correct Answer is A

Explanation

Choice A rationale:

Withholding the digoxin dose for a decreased heart rate is the correct action. Digoxin is a medication used to treat heart failure, but it can lead to bradycardia (slow heart rate) as a side effect. In this scenario, the client's heart rate is already at 54 beats per minute, which is below the normal range. Administering digoxin could further slow the heart rate, potentially leading to dangerous bradycardia or heart block. Withholding the medication is essential to prevent this adverse event.

Choice B rationale:

Administering digoxin 0.25 mg is not the appropriate action in this case. The client's heart rate is already below the normal range, and giving the full dose of digoxin could further depress the heart rate and increase the risk of bradycardia. Withholding the medication is the safer course of action.

Choice C rationale:

Administering digoxin 0.125 mg is not recommended because the client's heart rate is already below the normal range. While a reduced dose may be considered in some situations, it's essential to withhold the medication and consult with the healthcare provider in this specific case, as the client's heart rate is significantly low.

Choice D rationale:

Withholding the digoxin dose for elevated BP is not the appropriate action. Digoxin is primarily used to treat heart failure by increasing the force of cardiac contractions. Elevated blood pressure is not an indication to withhold digoxin. The focus should be on addressing the low heart rate in this scenario. .

View Question and Answer

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

A nurse administered nitroglycerin sublingually to a client who has angina pectoris and experienced chest pain.The client states that his chest pain is relieved but now he has a headache.Which of the following responses by the nurse is appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing a client's laboratory results. Which of the following findings should the nurse report to the provider?

Correct Answer is B

Explanation

A nurse is caring for a client who has a prescription for digoxin 0.25 mg P.O. daily for heart failure.The client's current vital signs are: BP 144/96, heart rate 54/min, respirations 18/min, and temperature 37°C (98.6°F). Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is collecting data from a client who has emphysema.Which of the following findings should the nurse expect? (Select all that apply.).

A nurse reviewing the laboratory of a client who had a total thyroidectomy discovers that his calcium level is 7 mg/dL. Which of the following client findings should the nurse expect?

A nurse is collecting data from a client who has heart failure, prior to the administration of furosemide. For which of the following findings should the nurse withhold the medication?

A nurse is conducting a preoperative interview with a client who is scheduled for surgery.The client states that he takes acetylsalicylic acid 81 mg. by mouth daily.Prior to the client's upcoming surgery, the nurse should instruct the client to do which of the following?

A nurse is assisting with planning interventions for an influenza outbreak in a long-term care facility.Which of the following interventions should the nurse include in the plan?

A nurse is reviewing the arterial blood gas (ABG) results of a client. The client's ABGs are:. A. pH: 7.6. B. PaCO2: 40 mm Hg. C. HCO3: 32 mEq/L. Which of the following acid-base conditions should the nurse identify the client is experiencing?

A nurse is collecting data from an older adult who is postoperative and receiving IV therapy at 125 mL/hr. The nurse should identify that which of the following findings indicates the client is experiencing fluid volume overload? (Select all that apply.).

A nurse is collecting data from a client who has a sodium level of 155 mEq/L. Which of the following manifestations should the nurse expect?

A nurse administered nitroglycerin sublingually to a client who has angina pectoris and experienced chest pain.
The client states that his chest pain is relieved but now he has a headache.
Which of the following responses by the nurse is appropriate?