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.”.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
"Pitting edema of the lower legs.”. Pitting edema is a common sign of congestive heart failure (CHF), and it often occurs bilaterally in the lower extremities. While this is a potential finding in left-sided heart failure, it is not specific to it.
Choice B rationale:
"Jugular venous distention.”. Jugular venous distention (JVD) is more indicative of right-sided heart failure or elevated central venous pressure. It is not a typical finding in left-sided heart failure.
Choice C rationale:
"Shortness of breath while lying down.”. This is a classic symptom of left-sided heart failure, known as orthopnea. When the patient lies flat, fluid that has accumulated in the lungs can lead to difficulty breathing. Patients with left-sided heart failure often find relief by sleeping with their upper body elevated.
Choice D rationale:
"Right upper quadrant pain.”. Right upper quadrant pain is not a typical finding in left-sided heart failure. It may be associated with issues related to the liver or gallbladder but is not directly related to heart failure.
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. .
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