A nurse in the emergency department is caring for a client who took three nitroglycerin tablets sublingually for chest pain. The client reports relief from the chest pain but now is experiencing a headache. Which of the following statements should the nurse make?

"A headache is an expected side effect of the medication."

"A headache is an indication of an allergy to the medication."

"A headache is likely due to the anxiety about the chest pain."

"A headache indicates tolerance to the medication."

Answer and Explanation

The Correct Answer is A

Choice A reason : Headaches are a common side effect of nitroglycerin due to its vasodilatory effects, which can cause blood vessels to expand, leading to headaches. Patients should be informed that this is a common reaction and can be managed with over-the-counter pain relievers if necessary¹²³⁴.

Choice B reason : A headache is not typically an indication of an allergy to nitroglycerin. Allergic reactions would more likely present with symptoms such as rash, itching, or difficulty breathing.

Choice C reason : While anxiety can cause headaches, in this context, the headache is more likely a direct side effect of the nitroglycerin, especially since it occurred after taking the medication and the chest pain was relieved.

Choice D reason : Tolerance to medication refers to a reduced response to a drug over time, requiring higher doses to achieve the same effect. A headache after taking nitroglycerin does not indicate tolerance; it is a known side effect of the drug.

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Correct Answer is D

Explanation

Choice A reason : Anticoagulants are medications that prevent blood clots. They are not typically used to manage fluid volume excess in left-sided heart failure. Instead, they may be used if the patient has an increased risk of clotting due to reduced mobility or atrial fibrillation, which can be associated with heart failure⁵.

Choice B reason : Antiembolism stockings are used to prevent deep vein thrombosis (DVT) and are not directly related to the management of fluid volume excess. They may be used in heart failure patients to prevent DVT due to reduced mobility but do not aid in fluid reduction⁵.

Choice C reason : Oxygen therapy can be used in left-sided heart failure to alleviate symptoms of dyspnea due to pulmonary congestion. However, it does not directly reduce fluid volume excess. It is a supportive treatment to ensure adequate oxygenation⁵.

Choice D reason : Diuretics are the primary treatment for reducing fluid volume excess in left-sided heart failure. They work by increasing urine output, which helps to reduce the volume of fluid in the body and alleviate symptoms such as pulmonary edema and peripheral edema⁵.

A. Exercise at least three times per week. B. Take naproxen sodium for generalized discomfort. C. Take diuretics early in the morning and before bedtime. D. Notify the provider of a weight gain of 0.5 kg (1 lb) in a week.

Correct Answer is A

Explanation

Choice A reason : Regular exercise, as tolerated and recommended by a healthcare provider, is beneficial for heart failure patients as it can improve cardiovascular health and overall well-being⁵.

Choice B reason : Taking naproxen sodium for generalized discomfort is not recommended for heart failure patients as nonsteroidal anti-inflammatory drugs (NSAIDs) can worsen heart failure by causing fluid retention and increasing blood pressure⁵.

Choice C reason : Taking diuretics early in the morning is advised to avoid nocturia; however, taking them before bedtime is not recommended for the same reason, as it can disrupt sleep due to the need for frequent urination⁵.

Choice D reason : Patients should be instructed to notify their healthcare provider of a weight gain of 0.5 kg (1 lb) in a week as it may indicate fluid retention, which is a common issue in heart failure⁵.

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A nurse in the emergency department is caring for a client who took three nitroglycerin tablets sublingually for chest pain. The client reports relief from the chest pain but now is experiencing a headache. Which of the following statements should the nurse make?

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