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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Drinking water in hot weather is important to prevent dehydration. This is not a risk factor for metabolic alkalosis unless the client is excessively losing electrolytes through sweating and not replacing them.
B. Sodium bicarbonate is an alkaline substance, and regular use, especially after meals, can contribute to metabolic alkalosis. The client should be instructed on the potential risks of using sodium bicarbonate too frequently.
C. Avoiding milk due to gastrointestinal symptoms does not directly contribute to metabolic alkalosis.
D. Digoxin does not directly affect acid-base balance, but it requires monitoring due to potential interactions with other medications or electrolyte imbalances.
Correct Answer is C
Explanation
A. A mild pain level of 3/10 is common after angioplasty and is not immediately concerning.
B. Minimal bruising at the groin is expected after this procedure and is not alarming.
C. A weakened pedal pulse and a cool leg could indicate compromised circulation, which is a serious concern post-angioplasty. Immediate assessment is needed to check for possible complications such as re-occlusion.
D. A blood pressure of 154/78 mmHg is somewhat elevated but not alarming.
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