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 ["B","C"]
Explanation
The nurse should contact the provider and ask the patient if they are feeling light headed or dizzy.
Choice A is wrong because administering the medication could worsen the patient’s condition.Furosemide is a diuretic that can cause dehydration, electrolyte imbalance, and hypotension.The patient already has a low serum potassium level of 2.8 mEq/L, which is below the normal range of 3.5 to 5.0 mEq/L.Giving furosemide could lower the potassium level further and increase the risk of cardiac arrhythmias.The patient also has a significant drop in blood pressure from lying to sitting position, which indicates orthostatic hypotension.Giving furosemide could lower the blood pressure more and cause dizziness, fainting, or falls.
Choice D is wrong because encouraging the patient to get up quickly and walk around could also cause dizziness, fainting, or falls due to orthostatic hypotension.The patient should be advised to change positions slowly and carefully, and to avoid activities that require alertness until their blood pressure stabilizes.
Choice E is wrong because holding the medication without contacting the provider could delay the appropriate treatment for the patient’s fluid retention.The nurse should notify the provider of the patient’s vital signs, laboratory results, and symptoms, and follow their orders regarding the medication dosage or alternative therapy.
Correct Answer is A
Explanation
Digoxin is a medication that can help the heart pump more blood and slow down the heart rate in certain conditions, such as heart failure and atrial fibrillation.However, digoxin has a narrow therapeutic range, which means that too much or too little of it can be harmful.The therapeutic range of digoxin levels in the blood is 0.5-2 ng/mL, and the toxic level is >2.4 ng/mL.Digoxin should be held if the resting apical pulse of an infant is <90 bpm, an older child is <70 bpm, or an adult is <60 bpm.A pulse of 48/min in an adult is too low and could indicate digoxin toxicity, which can cause life-threatening arrhythmias. Therefore, the nurse should withhold the dose and notify the health care provider immediately.
Choice B is wrong because notifying the health care provider and monitoring the patient’s vital signs are not enough.
The nurse should also withhold the dose to prevent further exposure to digoxin.
Choice C is wrong because rechecking the pulse, making sure to count for 1 full minute, is not necessary.The nurse should already have counted the pulse for 1 full minute before administering digoxin, as per standard procedure.
Choice D is wrong because administering the dose could worsen the patient’s condition and increase the risk of digoxin toxicity and arrhythmias.
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