A nurse in the emergency department is caring for a client who took three nitroglycerin tablets sublingually for chest pain. The client reports relief from the chest pain but now is experiencing a headache. Which of the following statements should the nurse make?

"A headache is an expected side effect of the medication."

"A headache is an indication of an allergy to the medication."

"A headache is likely due to the anxiety about the chest pain."

"A headache indicates tolerance to the medication."

Answer and Explanation

The Correct Answer is A

Choice A reason : Headaches are a common side effect of nitroglycerin due to its vasodilatory effects, which can cause blood vessels to expand, leading to headaches. Patients should be informed that this is a common reaction and can be managed with over-the-counter pain relievers if necessary¹²³⁴.

Choice B reason : A headache is not typically an indication of an allergy to nitroglycerin. Allergic reactions would more likely present with symptoms such as rash, itching, or difficulty breathing.

Choice C reason : While anxiety can cause headaches, in this context, the headache is more likely a direct side effect of the nitroglycerin, especially since it occurred after taking the medication and the chest pain was relieved.

Choice D reason : Tolerance to medication refers to a reduced response to a drug over time, requiring higher doses to achieve the same effect. A headache after taking nitroglycerin does not indicate tolerance; it is a known side effect of the drug.

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Correct Answer is D

Explanation

Choice A reason : Elevating the head of the bed to 20 degrees can help reduce intracranial pressure by promoting venous drainage from the brain. It is a recommended practice unless contraindicated by other conditions³.

Choice B reason : Cleansing the eyes with normal saline every 4 hours is a standard care procedure to maintain eye hygiene and prevent infection, especially when the blink reflex may be compromised in an unconscious patient³.

Choice C reason : Lubricating the skin with baby oil is a common practice to prevent dryness and maintain skin integrity. It is not contraindicated unless the patient has specific allergies or skin conditions that require different care³.

Choice D reason : Suctioning the oropharynx routinely is contraindicated as it can stimulate the vagus nerve and potentially increase intracranial pressure. Suctioning should be performed cautiously and only when necessary³.

A. Give morphine IV. B. Start an IV infusion of lactated Ringer's. C. Initiate cardiac monitoring. D. Administer oxygen therapy.

Correct Answer is D

Explanation

Choice A reason : While morphine IV can be used to alleviate pain and anxiety, it is not the first-line intervention for a pulmonary embolism. The primary concern in pulmonary embolism is to address the impaired gas exchange and potential hypoxemia¹.

Choice B reason : Starting an IV infusion of lactated Ringer's may be part of the overall management but is not the immediate priority. The initial focus should be on stabilizing the client's respiratory status¹.

Choice C reason : Initiating cardiac monitoring is important for observing the client's heart function, as pulmonary embolism can lead to strain on the heart. However, the first intervention should be to ensure adequate oxygenation¹.

Choice D reason : Administering oxygen therapy is the most critical initial intervention for a client with a pulmonary embolism. Oxygen therapy helps to manage hypoxemia and reduce the workload on the heart by improving oxygen saturation levels¹.

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A nurse in the emergency department is caring for a client who took three nitroglycerin tablets sublingually for chest pain. The client reports relief from the chest pain but now is experiencing a headache. Which of the following statements should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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