A nurse administered nitroglycerin sublingually to a client who has angina pectoris and experienced chest pain.
The client states that his chest pain is relieved but now he has a headache.
Which of the following responses by the nurse is appropriate?

"A headache indicates tolerance to the medication.”.

"It sounds as if you are allergic to this medication.”.

"A headache is a common adverse effect of this medication, but it will probably occur less often over time.”.

"Your headache is probably a result of anxiety about the chest pain.”.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Tolerance to nitroglycerin is not indicated by the presence of a headache. Nitroglycerin is a vasodilator used to relieve angina, and headaches can be a common side effect.

Choice B rationale:

Allergic reactions to nitroglycerin are rare, and a headache is not a typical symptom of an allergy to this medication.

Choice C rationale:

"A headache is a common adverse effect of this medication, but it will probably occur less often over time.”. This is the correct response. Nitroglycerin commonly causes headaches due to its vasodilatory effects. Patients often experience this side effect initially, but it tends to improve or occur less frequently with continued use. The nurse should educate the client about this and reassure them that the headaches should diminish over time.

Choice D rationale:

Anxiety may exacerbate chest pain, but it is not the likely cause of the headache. It is important to address the headache as a potential side effect of the medication.

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Correct Answer is C

Explanation

Choice A rationale:

Administer IV morphine. Administering IV morphine may be necessary for pain management in a client with a pulmonary embolism. However, pain relief should not take precedence over ensuring the patient's oxygenation and cardiovascular stability. Oxygen therapy is the top priority to address hypoxia and prevent further deterioration. Once oxygenation is secured, pain management can be considered.

Choice B rationale:

Start an IV infusion of lactated Ringer's. Initiating an IV infusion of lactated Ringer's solution may be important for maintaining hydration and electrolyte balance in a patient with a pulmonary embolism. However, this is not the top priority when a client is at risk of or experiencing a pulmonary embolism. Ensuring oxygenation and cardiovascular stability takes precedence. Once the patient is stable, intravenous fluids can be administered if needed.

Choice D rationale:

Initiate cardiac monitoring. Initiating cardiac monitoring is important in assessing the patient's cardiac rhythm and identifying any dysrhythmias or changes that may occur due to the pulmonary embolism. While this is a vital step, it is not the highest priority when the client is in a state of hypoxia and respiratory distress. Oxygen therapy should be the first intervention to address the immediate threat to the patient's life.

A. Have the client cough and expectorate secretions. B. Instruct the client to use a pursed-lip breathing technique. C. Increase the oxygen flow to 3 L/min. D. Evaluate the client's respiratory status.

Correct Answer is D

Explanation

Choice A rationale:

Having the client cough and expectorate secretions is a reasonable intervention for managing respiratory distress, but it is not the top priority. The nurse should first assess the client's overall respiratory status to determine the severity of the problem.

Choice B rationale:

Instructing the client to use a pursed-lip breathing technique is a helpful strategy to improve breathing in some cases. However, it should not be the top priority when a client is experiencing difficulty breathing. Assessment should come first.

Choice C rationale:

Increasing the oxygen flow to 3 L/min without a proper assessment is not advisable. It's essential to evaluate the client's respiratory status before making any adjustments to the oxygen therapy.

Choice D rationale:

"Evaluate the client's respiratory status" is the correct response. When a client with COPD and oxygen therapy reports difficulty breathing, the nurse's priority is to assess the client's respiratory status. This assessment will help determine the cause of the breathing difficulty and guide appropriate interventions. The nurse should also check the oxygen saturation levels, respiratory rate, and auscultate lung sounds to assess the severity of the issue.

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A nurse administered nitroglycerin sublingually to a client who has angina pectoris and experienced chest pain.The client states that his chest pain is relieved but now he has a headache.Which of the following responses by the nurse is appropriate?

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A nurse administered nitroglycerin sublingually to a client who has angina pectoris and experienced chest pain.
The client states that his chest pain is relieved but now he has a headache.
Which of the following responses by the nurse is appropriate?