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.

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Correct Answer is A

Explanation

Choice A rationale:

Check the client's respiratory rate and lung sounds When an IV bag is unexpectedly empty, it is important to assess the client for potential complications, especially if the client was receiving fluid therapy. Checking the respiratory rate and lung sounds is essential to ensure there are no signs of respiratory distress, such as crackles or wheezing, which could indicate fluid overload or a pulmonary issue.

Choice B rationale:

Request NPO status for the client Requesting nothing by mouth (NPO) status is not the immediate action required when an IV bag is empty. The priority is to assess the client's condition and address any potential issues first.

Choice C rationale:

Elevate the head of the bed to high Fowler's Elevating the head of the bed to high Fowler's is a measure to assist with preventing aspiration during oral intake. It is not the primary action required in this situation, where assessing the client's respiratory and fluid status is more important.

Choice D rationale:

Measure the client's temperature Measuring the client's temperature is not the immediate priority in this scenario. Assessing the client's respiratory and fluid status is more critical to identify any potential issues associated with the empty IV bag. .

A. A client who takes glyburide for type 2 diabetes mellitus. B. A client who takes furosemide for hypertension. C. A client who takes cimetidine to reduce gastric acid secretion. D. A client who takes azelastine for allergic rhinitis.

Correct Answer is B

Explanation

Choice A rationale:
A client who takes glyburide for type 2 diabetes mellitus is not at significant risk for developing digoxin toxicity. Glyburide is an antidiabetic medication and does not interact directly with digoxin.

Choice B rationale: Furosemide, a loop diuretic, can cause electrolyte imbalances such as hypokalemia (normal potassium levels: 3.5 to 5.0 mEq/L) and hypomagnesemia (normal magnesium levels: 1.7 to 2.2 mg/dL). These imbalances increase the sensitivity to digoxin and the risk of toxicity. Digoxin toxicity is associated with symptoms like nausea, vomiting, and arrhythmias. Furosemide's impact on electrolytes makes it a significant risk factor for digoxin toxicity.

Choice C rationale: Cimetidine, a histamine H2 receptor antagonist, can inhibit the metabolism of certain drugs by affecting liver enzymes. However, it does not significantly alter digoxin levels or increase the risk of toxicity. Normal liver enzyme levels include ALT (7 to 56 U/L) and AST (10 to 40 U/L). While cimetidine may interact with other medications, its effect on digoxin is minimal.

Choice D rationale:
A client who takes azelastine for allergic rhinitis is not at significant risk for developing digoxin toxicity. Azelastine is an antihistamine and does not interact directly with digoxin.

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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?

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Naxlex Comprehensive Predictor Exams

During a change-of-shift report, a nurse sees that a client's IV bag of 0.9% sodium chloride has 900 mL of fluid left in it. The nurse makes rounds 30 minutes later and notes that the IV bag is empty.Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse in a provider's office is reviewing the laboratory results of four clients who take digoxin. Which of the following clients is at risk for developing digoxin toxicity?

Correct Answer is B

Explanation

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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?