Nokea
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. A headache is an indication of an allergy to the medication.
- B. A headache is an expected adverse effect of the medication.
- C. A headache is likely due to the anxiety about the chest pain.
- D. A headache indicates tolerance to the medication.
Correct Answer: B
Rationale: Headaches are a common side effect of nitroglycerin due to its vasodilating effects on cerebral arteries.
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A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse expect?
- A. Heart murmur
- B. Dependent edema
- C. Chest pain
- D. Crackles in the lungs
Correct Answer: B
Rationale: Dependent edema occurs in right-sided HF due to systemic venous congestion.
The nurse is caring for a client with advanced cirrhosis. Which of the following clinical manifestations should the nurse recognize as a serious complication of this condition?
- A. Frequent nosebleeds and bruising
- B. Urinary retention
- C. No bowel movement in three days
- D. Increased blood glucose
Correct Answer: A
Rationale: Coagulopathy (evidenced by bleeding) is serious in cirrhosis due to impaired clotting factor production.
A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering?
- A. Atropine
- B. Furosemide
- C. Heparin
- D. Dexamethasone
Correct Answer: C
Rationale: Heparin is an anticoagulant used in the initial treatment of pulmonary embolism to prevent further clot formation.
A nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse that the client is developing this condition?
- A. Anorexia
- B. Weight gain
- C. Distended abdomen
- D. Dyspnea
Correct Answer: D
Rationale: Dyspnea is a hallmark symptom of left-sided heart failure due to pulmonary congestion from blood backing up into the lungs.
A nurse is assessing a client who has an obstruction of the common bile duct resulting from chronic cholecystitis. Which of the following findings should the nurse expect?
- A. Tenderness in the left upper abdomen
- B. Ecchymosis of the extremities
- C. Pale-colored urine
- D. Fatty stools
Correct Answer: D
Rationale: Fatty stools (steatorrhea) occur with common bile duct obstruction because bile cannot reach the intestine to emulsify fats.