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A nurse assesses a client after administering the first dose of a nitrate. The client reports a headache. What action would the nurse take?

Instruct the client to drink water.

Hold the next dose.

Initiate oxygen therapy.

Administer PRN acetaminophen.

Answer and Explanation

The Correct Answer is D

A. Drinking water is not likely to alleviate the headache caused by the nitrate.

B. Holding the next dose is not necessary unless the headache becomes severe or is associated with other symptoms.

C. Initiating oxygen therapy is unnecessary for a headache caused by nitrate use.

D. A headache is a common side effect of nitrate administration due to the vasodilation effect. Administering PRN acetaminophen can help relieve the headache.

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Correct Answer is A

Explanation

A. A 19-year-old client with menorrhagia who has been using superabsorbent tampons and has fever with weakness: This is the correct choice. Fever and weakness in the context of menorrhagia suggest a possible infection (e.g., toxic shock syndrome) or severe blood loss, which requires immediate evaluation and intervention.

B. A 35-year-old client with heavy spotting after having a progestin-containing IUD (Mirena) inserted a month ago: Spotting after IUD insertion is common and does not suggest an immediate threat to the client’s health.

C. A 39-year-old client who is complaining of 4/10 pain after an abdominal hysterectomy: Mild pain after a hysterectomy is expected and not an emergency.

D. A 42-year-old client with secondary amenorrhea who says that her last menstrual cycle was 3 months ago: While secondary amenorrhea requires evaluation, it is not as urgent as a client with signs of possible infection or blood loss.

A. Adenosine 6 mg IV push B. Immediate cardioversion C. Adenosine 12 mg IV push D. Amiodarone 150 mg bolus followed by a 24 hour drip

Correct Answer is B

Explanation

A. Adenosine 6 mg IV push: Adenosine is used for certain supraventricular tachycardias, but immediate cardioversion is the first priority for a client with atrial flutter and chest pain.

B. Immediate cardioversion: This is the correct answer. Immediate cardioversion is indicated for atrial flutter with signs of hemodynamic instability, such as chest pain and shortness of breath.

C. Adenosine 12 mg IV push: Adenosine may be used after the first dose of 6 mg if the initial dose was ineffective, but cardioversion takes precedence for unstable patients.

D. Amiodarone 150 mg bolus followed by a 24-hour drip: Amiodarone is an antiarrhythmic used for rate control or rhythm conversion but is not the first step for hemodynamically unstable clients with atrial flutter.

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A nurse assesses a client after administering the first dose of a nitrate. The client reports a headache. What action would the nurse take?

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