A male client reports to the on-call clinic nurse that he took tadalafil 10 mg by mouth two hours ago and his skin now feels flushed. He reports a history of stable angina, but denies experiencing any current or recent chest pain. Which action should the nurse take?
Advise the client to place one nitroglycerin tablet under his tongue as a precaution.
Tell the client to have someone bring him to an emergency department immediately.
Instruct the client to increase his intake of oral fluids until the skin flushing is relieved.
Reassure the client that skin flushing is a common side effect of the medication.
The Correct Answer is D
Choice A: Advising the client to place one nitroglycerin tablet under his tongue as a precaution is a dangerous action for the nurse, as this can cause severe hypotension and cardiovascular collapse due to the interaction between tadalafil and nitroglycerin. This is a contraindicated choice.
Choice B: Telling the client to have someone bring him to an emergency department immediately is an unnecessary action for the nurse, as there is no evidence of any serious adverse reaction or complication from tadalafil. This is an overreaction choice.
Choice C: Instructing the client to increase his intake of oral fluids until the skin flushing is relieved is not an appropriate action for the nurse, as this does not address the cause of the flushing, which is vasodilation due to tadalafil. This is a distractor choice.
Choice D: Reassuring the client that skin flushing is a common side effect of the medication is an appropriate action for the nurse, as this can calm the client and educate him about the expected effects of tadalafil. Therefore, this is the correct choice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: A 14-year-old client with anorexia nervosa refusing to eat the evening snack is a concern, but it’s not an immediate threat. The nurse can address this issue after dealing with more urgent situations.
Choice B: An 18-year-old client with antisocial behavior being yelled at by other clients requires immediate attention. This situation can escalate quickly and may lead to physical harm or emotional distress for the client.
Choice C: A 16-year-old client diagnosed with major depression refusing to participate in group is a concern, but it’s not an immediate threat. The nurse can address this issue after dealing with more urgent situations.
Choice D: A 17-year-old client diagnosed with bipolar disorder pacing around the lobby might be experiencing agitation or restlessness, but unless they’re showing signs of immediate distress or posing a risk to themselves or others, it’s not the most urgent situation.
Correct Answer is C
Explanation
Choice A: When the client has ankle edema is not the most important time for the nurse to assess DTRs, as this is a common finding in pregnancy and does not indicate a neurological or vascular problem. This is a distractor choice.
Choice B: Within the first trimester of pregnancy is not the most important time for the nurse to assess DTRs, as this is a routine assessment that can be done at any time during pregnancy and does not reflect any specific risk or complication. This is another distractor choice.
Choice C: If the client has an elevated blood pressure is the most important time for the nurse to assess DTRs, as this can indicate preeclampsia, a serious condition that can cause seizures, stroke, and organ damage. DTRs can help detect hyperreflexia, which is a sign of increased intracranial pressure and impending eclampsia. Therefore, this is the correct choice.
Choice D: During admission to labor and delivery is not the most important time for the nurse to assess DTRs, as this is a standard assessment that can be done at any stage of labor and does not signify any urgent or emergent situation. This is another distractor choice.
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