A nurse teaches a client with angina pectoris that he or she needs to take up to three sublingual nitroglycerin tablets at 5-minute intervals and immediately notify the health care provider if chest pain doesn’t subside within 15 minutes. What symptoms may the client experience after taking the nitroglycerin?
Nausea, vomiting, depression, fatigue, and impotence.
Sedation, nausea, vomiting, constipation, and respiratory depression.
Headache, hypotension, dizziness, and flushing.
Flushing, dizziness, headache, and pedal edema.
The Correct Answer is C
Choice A reason: Nausea and vomiting may occur with nitroglycerin, but depression, fatigue, and impotence are unrelated. Headache and hypotension are primary effects, making this incorrect, as it includes irrelevant symptoms compared to the nurse’s teaching on nitroglycerin’s expected side effects.
Choice B reason: Sedation, constipation, and respiratory depression are opioid effects, not nitroglycerin, which causes vasodilation. Dizziness and flushing are correct, making this incorrect, as it misattributes opioid side effects to nitroglycerin in the nurse’s education for angina management.
Choice C reason: Nitroglycerin causes headache, hypotension, dizziness, and flushing due to vasodilation, common side effects. This aligns with pharmacological education for angina, making it the correct set of symptoms the nurse would teach the client to expect after taking sublingual nitroglycerin.
Choice D reason: Pedal edema is not a nitroglycerin side effect, though flushing, dizziness, and headache are. Hypotension is more precise than edema, making this incorrect, as it includes an unrelated symptom compared to the accurate side effects in nitroglycerin teaching.
Choice E reason: Decreased cardiac output and peripheral edema are not nitroglycerin effects; it improves coronary flow. Flushing is correct, but hypotension is key, making this incorrect, as it misrepresents nitroglycerin’s pharmacological effects in the nurse’s teaching for angina relief.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E","G","I"]
Explanation
Choice A reason: Decreased cardiac output is a hallmark of cardiogenic shock, as the heart fails to pump adequately. This aligns with shock pathophysiology, making it a correct manifestation the nurse would expect when assessing a client for cardiogenic shock in a clinical setting.
Choice B reason: Increased pulse rate occurs in cardiogenic shock as the body compensates for low cardiac output. This aligns with cardiovascular assessment findings, making it a correct manifestation the nurse would identify in a client experiencing cardiogenic shock during evaluation.
Choice C reason: Postural hypotension is more typical of hypovolemic or orthostatic issues, not cardiogenic shock, which features weak pulses. Weak thready pulse is correct, making this incorrect, as it’s not a primary sign of cardiogenic shock in the nurse’s assessment.
Choice D reason: Bounding pulse suggests hyperdynamic circulation, not cardiogenic shock, where perfusion is poor. Weak thready pulse is typical, making this incorrect, as it does not reflect the compromised cardiac output expected in the nurse’s evaluation of cardiogenic shock.
Choice E reason: Weak thready pulse indicates poor perfusion in cardiogenic shock due to reduced cardiac output. This aligns with peripheral vascular assessment, making it a correct manifestation the nurse would expect when assessing a client in cardiogenic shock.
Choice F reason: Hypertension is not typical in cardiogenic shock, which often presents with hypotension due to pump failure. Pink frothy sputum is correct, making this incorrect, as it contradicts the hemodynamic profile in the nurse’s assessment of cardiogenic shock.
Choice G reason: Capillary refill greater than 3 seconds reflects poor perfusion in cardiogenic shock, consistent with low cardiac output. This aligns with peripheral assessment findings, making it a correct manifestation the nurse would note in a client with cardiogenic shock.
Choice H reason: Capillary refill less than 3 seconds suggests normal perfusion, not cardiogenic shock, where refill is delayed. Greater than 3 seconds is correct, making this incorrect, as it does not align with the poor perfusion in cardiogenic shock assessment.
Choice I reason: Pink frothy sputum indicates pulmonary edema, common in cardiogenic shock due to left heart failure. This aligns with respiratory assessment findings, making it a correct manifestation the nurse would expect in a client with cardiogenic shock.
Correct Answer is D
Explanation
Choice A reason: Nonmaleficence ensures no harm but is less central than veracity, which ensures truthful disclosure for informed consent. Truthfulness enables autonomous decisions, making this incorrect, as it’s secondary to the ethical priority of honesty in the consent process for femur surgery.
Choice B reason: Fidelity involves keeping promises but doesn’t directly address the truthful disclosure required for informed consent. Veracity ensures the patient understands risks, making this incorrect, as it’s less relevant than honesty in the nurse’s role during the consent process for surgery.
Choice C reason: Beneficence promotes well-being but is secondary to veracity, which provides accurate information for the patient’s decision. Truthfulness is critical for consent, making this incorrect, as it’s not the primary ethical principle when soliciting informed consent for the femur procedure.
Choice D reason: Veracity, or truthfulness, is the most important ethical principle, ensuring the patient receives accurate information about risks and benefits for informed consent. This aligns with surgical ethical standards, making it the correct principle for the nurse to prioritize during the consent process.
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