A nurse in the emergency department is caring for a client who took 3 nitroglycerin tablets sublingually for chest pain. The client reports relief from the chest pain but now he is experiencing a headache. Which of the following statements should the nurse make?
"A headache is an indication of an allergy to the medication."
"A headache indicates tolerance to the medication."
"A headache is likely due to the anxiety about the chest pain."
"A headache is an expected adverse effect of the medication."
The Correct Answer is D
A headache is a common and expected adverse effect of nitroglycerin, due to its vasodilating action. The client can take an over-the-counter analgesic to relieve the headache, unless contraindicated.
"A headache is an indication of an allergy to the medication." is not correct, as a headache is not a sign of an allergic reaction to nitroglycerin. An allergic reaction would manifest as rash, itching, swelling, or difficulty breathing.
"A headache indicates tolerance to the medication." is not accurate, as a headache does not indicate tolerance to nitroglycerin. Tolerance would manifest as reduced or absent relief from anginal pain.
"A headache is likely due to the anxiety about the chest pain." is not plausible, as a headache is not likely due to the anxiety about the chest pain. Anxiety would manifest as nervousness, restlessness, palpitations, or sweating.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Taking one tablet at the first indication of chest pain is the correct way to use SL nitroglycerin tablets, as they are fast- acting and can relieve anginal symptoms within minutes. The client should place the tablet under the tongue and let it dissolve.
Taking one tablet at the first indication of chest pain is the correct way to use SL nitroglycerin tablets, as they are fast- acting and can relieve anginal symptoms within minutes. The client should place the tablet under the tongue and let it dissolve.
Taking this medication after each meal and at bedtime is not appropriate, as SL nitroglycerin tablets are not meant for routine or prophylactic use, but only for acute episodes of angina.
Taking one tablet every 15 min during an acute attack is not correct, as the client should not exceed three doses in 15 min. If the pain is not relieved after three doses, the client should seek emergency medical attention.
Taking this medication with 8 ounces of water is not necessary, as SL nitroglycerin tablets do not need to be swallowed or washed down with water. They should be dissolved under the tongue for optimal absorption.
Correct Answer is D
Explanation
The nurse should place a towel under the client's head to protect it from injury during the seizure. The nurse should also loosen any tight clothing, remove any objects that could harm the client, and maintain a patent airway.
Place the client in a prone position is wrong because it can compromise the client's breathing and increase the risk of aspiration. The nurse should place the client in a side-lying position after the seizure to facilitate drainage of oral secretions and prevent aspiration.
Holding the client's arms and legs still is wrong because it can cause injury to the client or the nurse. The nurse should not restrain or interfere with the client's movements during the seizure but rather ensure a safe environment and observe the seizure activity.
Leaving the client to get help is wrong because it can endanger the client's safety and well-being. The nurse should stay with the client during the seizure and call for assistance if needed, but not leave the client alone or unattended.
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