A client arrives to the emergency department with chest pain after taking sildenafil. Based on the client's history, which medication should the nurse withhold?
Aspirin.
Nitroglycerin.
Morphine.
Heparin.
The Correct Answer is B
Rationale
A. Aspirin is commonly used in the emergency setting for chest pain suspected to be due to acute coronary syndrome (ACS), which includes conditions like myocardial infarction (heart attack). It works by reducing blood clotting and can help alleviate symptoms in some cases. It is typically safe to administer aspirin
B. Sildenafil can interact with nitrates, such as nitroglycerin, and result in a significant drop in blood pressure. Therefore, the nurse should withhold nitroglycerin to prevent potential adverse effects.
C. Morphine is a potent opioid pain medication used in the emergency department for severe pain relief, including chest pain associated with suspected myocardial infarction. It can help reduce pain and anxiety in acute coronary syndromes. It has no significant interaction with sildenafil.
D. Heparin is an anticoagulant medication used to prevent blood clotting. It is often administered in the hospital setting for various indications, such as deep vein thrombosis, pulmonary embolism, or in some cases of acute coronary syndromes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale
A. Troponin levels are cardiac biomarkers that are elevated in the blood when there is damage to the heart muscle, such as during a myocardial infarction (heart attack). Verifying the schedule for troponin assessments is important to monitor for myocardial damage and to guide treatment decisions.
B. This action is aimed at creating a quiet and calm environment for the client, which can help reduce anxiety and minimize stimuli that might exacerbate symptoms. Creating a conducive environment is beneficial for the client's comfort and well-being but should not delay urgent interventions required for acute symptoms.
C. PVCs are abnormal heartbeats that can occur in individuals with CAD and may indicate increased cardiac irritability or instability. While monitoring PVCs is important for assessing cardiac rhythm and potential complications, it is not the immediate priority over addressing acute symptoms such as shortness of breath, nausea, and chest pressure.
D. Oxygen therapy is essential in the management of a client with suspected ACS to improve oxygenation and reduce cardiac workload. Maintaining oxygen saturation above 93% helps ensure adequate tissue oxygenation, especially during episodes of chest discomfort and potential myocardial ischemia.
Correct Answer is B
Explanation
Rationale
A. This action is important to prevent unauthorized access to medications by the client or other patients. However, this is not the priority
B. Soft drink cans can potentially be used to harm oneself or others (e.g., by smashing or as a cutting tool). Removing these items helps to reduce the risk of self-injury or harm to others.
C. This action is typically done to safely dispose of any items that may be considered biohazardous, such as used tissues, bandages, or any items contaminated with bodily fluids. It helps to maintain infection control and prevent exposure to potentially infectious materials.
D. In some mental health units, clients may not be allowed to have personal electronic devices due to concerns about confidentiality, safety, or potential disruption. Providing a unit-controlled telephone allows staff to monitor communication and ensure it is appropriate and supportive
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