Practice Question
A nurse administered nitroglycerin sublingually to a client who has angina pectoris and experienced chest pain. The client states that his chest pain is relieved but now he has a headache. Which of the following responses by the nurse is appropriate?
Answer Choices:
Correct Answer:
A headache is a common adverse effect of this medication.
Rationale:
💊 Nitroglycerin causes vasodilation of blood vessels, including cerebral vessels, which commonly leads to headache as an expected adverse effect.
💊 The nurse should reassure the client that this is a known effect and not usually a sign of a serious problem when mild.
💊 Headaches from nitroglycerin can often be managed with acetaminophen or may lessen as the client develops tolerance over time.
💊 It is important to continue the medication as prescribed, because its primary role is to relieve myocardial ischemia and chest pain.
💊 Teaching the client that the headache is related to the drug’s action helps improve adherence and reduces anxiety.
“Your headache is probably a result of anxiety about the chest pain.”
💊 This response incorrectly attributes the headache to anxiety, ignoring the well-known pharmacologic effect of nitroglycerin.
💊 Minimizing the headache as “anxiety” fails to educate the client about true medication effects.
💊 It may undermine the client’s trust, as they might feel their symptom is being dismissed.
💊 The nurse’s role includes providing accurate information about common adverse effects, not guessing or mislabeling them.
💊 Therefore, this response is not appropriate and does not reflect evidence-based teaching.
“It sounds as if you are allergic to this medication.”
💊 An allergic reaction typically involves rash, itching, swelling, wheezing, or anaphylaxis, not just an isolated headache.
💊 A headache after nitroglycerin is due to vasodilation, not an immune-mediated allergy.
💊 Labeling this as an allergy could lead to unnecessary discontinuation of a life-saving medication.
💊 It may also result in incorrect allergy documentation in the medical record.
💊 Therefore, this statement is inaccurate and not appropriate.
“A headache indicates tolerance to the medication.”
💊 Tolerance to nitroglycerin usually means reduced therapeutic effect over time, not that an adverse effect like headache appears.
💊 Headache is most common when therapy is started or doses are increased, not as a marker of tolerance.
💊 Saying headache indicates tolerance misleads the client about drug effectiveness.
💊 This could result in confusion about when the medication is working properly or not.
💊 Therefore, this explanation is incorrect and should not be used.
Want to practice more questions like this?
This question is from ☑️Custom NSGP 132 Fall 25 Exam 2 which contains 39 questions.
More Questions from This Exam
A nurse is collecting data from a client who has an acute myocardial infarction (MI). Which of the following clinical manifestations should the nurse expect to find? (Select all that apply.)
Answer Choices:
A nurse is reviewing the health history of a patient with acute pancreatitis. The nurse knows that that which of the following are common causes of pancreatitis? (Select all that apply.)
Answer Choices:
A nurse is assisting in the plan of care for a client who has a suspected myocardial infarction. Which of the following should the nurse plan to administer first?
Answer Choices:
A nurse is caring for a client who has a deep vein thrombosis, who received IV heparin for the past 5 days, and now has a new prescription for oral warfarin in addition to the heparin. The client asks the nurse if both medications are necessary. Which of the following is an appropriate response by the nurse?
Answer Choices:
A nurse is caring for a client who has a new prescription for warfarin. The nurse should use the results of which of the following diagnostic tests to monitor the effect of this therapy?
Answer Choices:
Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI MedSurg
- Answer Choices: 4