A nurse in the emergency department is caring for a client who took 3 nitroglycerin tablets sublingually for chest pain. The client reports relief from the chest pain but now he is experiencing a headache. Which of the following statements should the nurse make?
"A headache is an indication of an allergy to the medication."
"A headache indicates tolerance to the medication."
"A headache is likely due to the anxiety about the chest pain."
"A headache is an expected adverse effect of the medication."
The Correct Answer is D
A headache is a common and expected adverse effect of nitroglycerin, due to its vasodilating action. The client can take an over-the-counter analgesic to relieve the headache, unless contraindicated.
"A headache is an indication of an allergy to the medication." is not correct, as a headache is not a sign of an allergic reaction to nitroglycerin. An allergic reaction would manifest as rash, itching, swelling, or difficulty breathing.
"A headache indicates tolerance to the medication." is not accurate, as a headache does not indicate tolerance to nitroglycerin. Tolerance would manifest as reduced or absent relief from anginal pain.
"A headache is likely due to the anxiety about the chest pain." is not plausible, as a headache is not likely due to the anxiety about the chest pain. Anxiety would manifest as nervousness, restlessness, palpitations, or sweating.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["8 mL"]
Explanation
To calculate the volume to administer, the nurse should use the following formula:
Volume (mL) = Dose (mg) / Concentration (mg/mL) x 1000
Plugging in the given values, the nurse should get:
Volume (mL) = 400 mg / 250 mg/5 mL x 1000
Volume (mL) = 8 mL
The nurse should round the answer to the nearest whole number and use a leading zero if it applies. Therefore, the nurse should administer 8 mL of valproic acid per dose.
Correct Answer is D
Explanation
Using elastic stockings is an effective way to improve venous return and prevent edema, stasis, and ulceration in clients who have venous insufficiency. The stockings should be applied before getting out of bed and worn throughout the day.
"Apply ice packs to your legs." is not appropriate, as ice packs can cause vasoconstriction and impair blood flow to the legs, worsening the condition.
"Place your legs in a dependent position while in bed." is not advisable, as dependent position can increase venous pressure and fluid accumulation in the legs, leading to edema, pain, and skin breakdown
"Remain on bed rest." is not necessary, as bed rest can reduce muscle contraction and impair venous return. The client should be encouraged to perform regular exercise, such as walking, to enhance circulation and prevent complications.
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