When administering sublingual nitroglycerin for emergency treatment of angina or chest pain, the nurse monitors for which common adverse effect?
Nausea.
Bradycardia.
Hypertension.
Headache.
The Correct Answer is D
The correct answer is Choice D: Headache.
Choice A rationale: Nausea is not a common adverse effect of sublingual nitroglycerin. Nausea may occur in some patients, but it is usually mild and transient. Nausea may be related to the vasodilatory effects of nitroglycerin, which can cause hypotension and reflex tachycardia1. Nausea may also be caused by other factors, such as anxiety, stress, or food intolerance. Nausea is not a specific indicator of nitroglycerin toxicity or overdose2.
Choice B rationale: Bradycardia is not a common adverse effect of sublingual nitroglycerin. Bradycardia is a slow heart rate, usually defined as less than 60 beats per minute. Bradycardia may occur in some patients who take nitroglycerin, especially in combination with other drugs that affect the heart rate, such as beta-blockers, calcium channel blockers, or digoxin3. Bradycardia may also be caused by other factors, such as vagal stimulation, hypothyroidism, or electrolyte imbalance. Bradycardia is not a specific indicator of nitroglycerin toxicity or overdose2.
Choice C rationale: Hypertension is not a common adverse effect of sublingual nitroglycerin. Hypertension is a high blood pressure, usually defined as more than 140/90 mmHg. Hypertension may occur in some patients who take nitroglycerin, especially in those who have a history of hypertension, renal impairment, or volume overload4. Hypertension may also be caused by other factors, such as stress, pain, or caffeine intake. Hypertension is not a specific indicator of nitroglycerin toxicity or overdose2.
Choice D rationale: Headache is a common adverse effect of sublingual nitroglycerin. Headache may occur in up to 80% of patients who take nitroglycerin, especially during the first few days of therapy or after an increase in dose5. Headache may be related to the vasodilatory effects of nitroglycerin, which can cause cerebral vasodilation and increased intracranial pressure. Headache may also be caused by other factors, such as dehydration, sinusitis, or migraine. Headache is usually mild to moderate in intensity and can be relieved by analgesics, such as acetaminophen or aspirin. Headache is not a specific indicator of nitroglycerin toxicity or overdose
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Food high in potassium should be avoided for clients taking ACE inhibitors. ACE inhibitors are drugs that block the conversion of angiotensin I to angiotensin II, which is a potent vasoconstrictor and also stimulates the secretion of aldosterone. Aldosterone is a hormone that increases the reabsorption of sodium and water and the excretion of potassium in the kidneys. By inhibiting angiotensin II, ACE inhibitors lower blood pressure and reduce the loss of potassium. However, this can also lead to hyperkalemia, which is a high level of potassium in the blood that can cause cardiac arrhythmias and muscle weakness.Therefore, clients taking ACE inhibitors should limit their intake of foods that are rich in potassium, such as bananas, oranges, tomatoes, potatoes, spinach, beans, nuts, and salt substitutes.
Choice B is wrong because a low sodium diet is recommended for clients taking ACE inhibitors.
A low sodium diet can help lower blood pressure and reduce fluid retention, which are beneficial effects for clients with hypertension, heart failure, or chronic kidney disease.A low-potassium diet should aim for potassium intake of less than 50 or 75 mmol/day and sodium intake of less than 60 mmol/day for hypertensive patients with chronic kidney disease.
Choice C is wrong because adequate fluid intake is not contraindicated for clients taking ACE inhibitors.
Adequate fluid intake can help prevent dehydration and maintain kidney function, especially in patients with diabetes or nephropathy.However, excessive fluid intake may worsen heart failure or edema in some patients, so fluid intake should be individualized and monitored according to the patient’s condition and response to therapy.
Choice D is wrong because foods low in potassium are not harmful for clients taking ACE inhibitors.
Foods low in potassium do not affect the serum potassium level or the risk of hyperkalemia in clients taking ACE inhibitors.However, foods low in potassium may not provide enough dietary potassium for normal cellular functions, so a balanced diet that includes moderate amounts of potassium-rich foods is advisable.
Correct Answer is C
Explanation
This is because potassium sparing diuretics do not lower potassium levels in the blood, unlike other types of diuretics.Potassium is an essential electrolyte that serves nerve and muscular functions and is regulated by the kidneys.Low potassium levels can cause irregular heartbeats and other problems. Therefore, patients taking potassium sparing diuretics should avoid food sources that are high in potassium, such as bananas, avocados, spinach, and potatoes.
Choice A is wrong because thiazide diuretics, such as hydrochlorothiazide, can cause low potassium levels in the blood.
Patients taking thiazide diuretics may need to take potassium supplements or eat more potassium-rich foods to prevent hypokalemia.
Choice B is wrong because osmotic diuretics, such as mannitol, do not affect potassium levels in the blood.
They work by increasing the amount of water in the urine, but do not alter the electrolyte balance.
Osmotic diuretics are mainly used to treat cerebral edema and glaucoma.
Choice D is wrong because loop diuretics, such as furosemide, can also cause low potassium levels in the blood.
They work by inhibiting the reabsorption of sodium and water in the loop of Henle, a part of the kidney.
Loop diuretics are used to treat edema and heart failure.
Normal ranges for potassium in the blood are 3.5 to 5.0 millimoles per liter (mmol/L).
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