Choice A rationale:

Planning to have the client lay down for 1 hour after meals is not an appropriate intervention for a client with COPD. It may increase the risk of aspiration and worsen their breathing difficulties.

Choice C rationale:

Encouraging the client to use the upper chest for respiration is not the best approach for a client with COPD. Pursed-lip breathing helps improve oxygen exchange and decreases air trapping, which is more effective in managing COPD.

Choice D rationale:

Restricting the client's fluid intake to less than 1 Vday is not a suitable intervention for a client with COPD. Dehydration can lead to thicker mucus, making it harder to breathe

Choice A rationale:

Bananas are a good source of potassium, and the client's serum potassium level is low (3.1 mEq/L). Including potassium-rich foods like bananas in the diet can help raise the potassium level and prevent hypokalemia, which is a potential side effect of furosemide (a diuretic).

Choice B rationale:

Cheddar cheese is not a suitable choice for a client with low potassium levels. It is not a significant source of potassium and should not be the primary recommendation for addressing hypokalemia.

Choice C rationale:

Cabbage is not a good choice for increasing potassium intake. While it has some potassium, other fruits and vegetables like bananas are much richer sources of this essential electrolyte.

Choice D rationale:

White rice is not a high-potassium food and should not be the first choice for a client with low potassium levels.

Choice A rationale:
Elevating the head of the bed to a 45-degree angle is important for clients with obstructive sleep apnea (OSA) to help prevent airway obstruction during sleep. However, this should not be the nurse's immediate priority before leaving the client. Ensuring the client's positive airway pressure (PAP) device is properly applied is more crucial.
Choice C rationale:
While locking the side rails in place is generally essential for safety, it is not the most critical intervention for a client with OSA and urination issues. Ensuring proper use of the PAP device is a higher priority.
Choice D rationale:
Removing dentures or other oral appliances is important for preventing airway obstruction in clients with OSA, but it should not take precedence over ensuring the use of the PAP device. The nurse should address the immediate respiratory needs of the client.

Choice A rationale:

Restricting visitation is an essential intervention during an influenza outbreak in a long-term care facility. Influenza is highly contagious and can spread rapidly among residents and staff in a close environment like a long-term care facility. By limiting visitation, the facility can reduce the risk of introducing the virus from the outside and help contain the outbreak. This is a preventive measure to protect vulnerable residents from exposure to the virus.

Choice B rationale:

Providing prophylactic antibiotics for clients who have been exposed to influenza is not a recommended intervention. Influenza is caused by a virus, not bacteria, so antibiotics are ineffective in preventing or treating the infection. Antibiotics should only be used to treat bacterial infections, not viral ones. Inappropriate use of antibiotics can lead to antibiotic resistance and other adverse effects.

Choice C rationale:

Implementing airborne precautions for clients who have influenza is not typically necessary. Influenza primarily spreads through respiratory droplets when an infected person coughs or sneezes. Standard precautions, such as proper hand hygiene and wearing masks when in close contact with infected individuals, are usually sufficient to prevent the spread of the virus. Airborne precautions are typically reserved for diseases that are transmitted through the airborne route, like tuberculosis.

Choice D rationale:

Assigning healthcare personnel to nondirect care activities for 24 hours after developing influenza symptoms is not a recommended intervention. While it's important for healthcare personnel to stay home when they are sick to prevent the spread of the virus, 24 hours may not be a necessary duration. The standard guideline for healthcare workers with influenza is to stay home until they are fever-free for at least 24 hours without the use of fever-reducing medications.

Choice A rationale:

Limiting fluid intake throughout the day is not a suitable instruction for a client diagnosed with emphysema. Emphysema is a chronic obstructive pulmonary disease (COPD), and adequate hydration is important for individuals with this condition. Dehydration can lead to thicker mucus in the airways, making it harder to breathe. Clients with emphysema should be encouraged to maintain proper hydration.

Choice B rationale:

Instructing the client to breathe in through her nose and out through pursed lips is a beneficial technique for improving gas exchange in emphysema. This breathing technique, known as pursed-lip breathing, helps slow down the exhalation and maintains positive pressure in the airways, which can prevent airway collapse. It also promotes better oxygen exchange and reduces the feeling of breathlessness.

Choice C rationale:

Consuming a low-protein diet is not advisable for a client with emphysema. Protein is essential for tissue repair and overall health. Clients with emphysema should follow a balanced diet to maintain their energy levels and support their respiratory function. Restricting protein intake is not a standard recommendation for managing emphysema.

Choice D rationale:

Instructing the client to rest in a supine position is not a suitable recommendation. Emphysema clients often find it easier to breathe when in an upright or semi-Fowler's position, as it allows for better lung expansion and oxygen exchange. Resting in a supine position can compromise their ability to breathe effectively and may worsen their symptoms.

Choice A rationale:

Hypovolemic shock is characterized by a decrease in blood volume, leading to low blood pressure and compensatory mechanisms such as a high pulse rate. When the body experiences a significant loss of blood or fluid, it attempts to maintain perfusion to vital organs by increasing the heart rate to ensure an adequate blood supply. Low blood pressure and a high pulse rate are classic signs of hypovolemic shock.

Choice B rationale:

A low BP and low pulse rate are not indicative of hypovolemic shock. Hypovolemic shock is associated with a rapid and weak pulse rate as the body tries to compensate for decreased blood volume. A low pulse rate could suggest other conditions, such as bradycardia, rather than hypovolemic shock.

Choice C rationale:

High BP and high pulse rate are not typical findings in hypovolemic shock. Hypovolemic shock is characterized by low blood pressure and a high pulse rate as the body attempts to compensate for the reduced blood volume. High blood pressure is more commonly associated with conditions like hypertension, not hypovolemic shock.

Choice D rationale:

High BP and low pulse rate are not consistent with the characteristics of hypovolemic shock. As mentioned earlier, hypovolemic shock is marked by low blood pressure and a high pulse rate due to the body's efforts to maintain adequate perfusion. High blood pressure and a low pulse rate may suggest other medical conditions unrelated to hypovolemic shock.

Choice A rationale:

Dyspnea is a common finding in clients with emphysema. Emphysema is a chronic obstructive pulmonary disease (COPD) characterized by the destruction of the alveoli in the lungs, leading to difficulty breathing and shortness of breath. The loss of alveoli reduces the surface area for gas exchange, causing dyspnea.

Choice B rationale:

Bradycardia is not typically associated with emphysema. In fact, it is more common for clients with emphysema to have an increased heart rate (tachycardia) due to the body's compensatory response to low oxygen levels in the blood.

Choice C rationale:

Clubbing of the fingers is often seen in clients with chronic respiratory conditions like emphysema. It is a result of chronic hypoxia and is characterized by the abnormal rounding and thickening of the fingertips and nail beds.

Choice D rationale:

Barrel chest is a common physical finding in clients with emphysema. It is characterized by an increase in the anteroposterior diameter of the chest due to overinflation of the lungs. This change in chest shape is a result of chronic air trapping and hyperinflation, which are hallmarks of emphysema.

Choice E rationale:

Shallow respirations are expected in clients with emphysema. Due to the loss of alveolar elasticity and increased airway resistance, clients with emphysema tend to take shallow breaths, which are less effective for oxygen exchange.

Choice A rationale:

Gastrointestinal bloating is not a typical clinical manifestation of left-sided heart failure. Left-sided heart failure primarily affects the pulmonary circulation, leading to symptoms such as dyspnea and orthopnea, but not gastrointestinal symptoms.

Choice B rationale:

Jugular vein distention is more commonly associated with right-sided heart failure. In left-sided heart failure, the congestion typically occurs in the pulmonary circulation, leading to respiratory symptoms, whereas jugular vein distention is a sign of elevated central venous pressure often seen in right-sided heart failure.

Choice C rationale:

Tachycardia is a common clinical manifestation of left-sided heart failure. As the heart struggles to pump blood effectively, it compensates by increasing the heart rate to maintain cardiac output.

Choice D rationale:

Orthopnea is a classic symptom of left-sided heart failure. Clients with left-sided heart failure often experience difficulty breathing when lying flat and find relief when sitting upright. This is due to the redistribution of blood in the lungs when changing positions.

Choice E rationale:

Dyspnea is another hallmark symptom of left-sided heart failure. It is caused by the accumulation of fluid in the lungs (pulmonary edema) due to the impaired ability of the left ventricle to effectively pump blood, leading to congestion in the pulmonary circulation.

Choice A rationale:

Cool, clammy skin is not a typical manifestation of hypernatremia (high sodium levels). Hypernatremia is characterized by an excess of sodium in the blood, which typically leads to symptoms such as thirst, dry mucous membranes, and decreased skin turgor. Cool, clammy skin is more often associated with conditions like shock or hypoglycemia.

Choice B rationale:

Increased salivation is not a common manifestation of hypernatremia. Instead, hypernatremia often leads to signs of dehydration, including dry mouth and decreased salivation.

Choice C rationale:

Hypertension is not a direct manifestation of hypernatremia. Hypernatremia can cause increased blood pressure, but it is not one of the typical clinical signs of hypernatremia. Hypertension is more commonly associated with conditions like high sodium intake, kidney disease, or primary hypertension.

Choice D rationale:

A decreased level of consciousness is a significant manifestation of hypernatremia. Elevated sodium levels in the blood can lead to cellular dehydration, affecting brain cells and resulting in neurological symptoms such as confusion, lethargy, and decreased consciousness. Severe hypernatremia can even lead to seizures and coma. .

Choice A rationale:

Albuterol primarily acts as a bronchodilator by opening up the airways. It does not have a significant anti-inflammatory effect. Inhaled corticosteroids are more commonly used to reduce airway inflammation in asthma.

Choice B rationale:

Albuterol, a beta-2 agonist, helps with breathing by relaxing the smooth muscles in the airways, which opens them up. This action allows for improved airflow and ease of breathing. Therefore, this choice is correct.

Choice C rationale:

Albuterol is used to relieve bronchospasm, which can prevent wheezing in individuals with asthma. It does not have a direct effect on reducing mucus production or coughing.

Choice D rationale:

Albuterol does not increase the amount of mucus production. In fact, it can help reduce coughing by relieving bronchospasm, but it does not directly suppress coughing episodes.

Choice E rationale:

Albuterol is not primarily used to decrease coughing episodes. While it can indirectly reduce coughing by opening the airways and relieving bronchospasm, its primary action is to dilate the airways, not to act as an antitussive.

Choice A rationale:

Skipping coffee on the morning of the exercise ECG stress test is a good idea as caffeine can affect heart rate and blood pressure, but it doesn't necessarily indicate the need for further instructions.

Choice B rationale:

Getting 8 hours of sleep the night before the test is a positive choice and promotes overall well-being, but it is not a specific indicator of needing further instructions for the test.

Choice C rationale:

Not smoking before the test is an appropriate action, as smoking can also affect heart rate and blood pressure during the test. However, it does not indicate a need for further instructions.

Choice D rationale:

Expecting to feel chest pain during an exercise ECG stress test is not correct and indicates a need for further instructions. Chest pain during the test can be a sign of cardiovascular issues and should be reported immediately.

Choice A rationale:

Captopril is an angiotensin-converting enzyme (ACE) inhibitor commonly used to treat heart failure. It does not typically cause a non-productive cough. In fact, ACE inhibitors are more likely to cause a dry, persistent cough.

Choice B rationale:

Metoprolol is a beta-blocker used in heart failure management. It is not associated with non-productive cough as a side effect.

Choice C rationale:

Furosemide is a loop diuretic and can cause a non-productive cough as a side effect. This is due to its potential to deplete potassium levels, which can irritate the airways and lead to coughing.

Choice D rationale:

Digoxin is used in heart failure to help the heart pump more effectively. While it can have various side effects, a non-productive cough is not typically associated with digoxin use. .

Choice A rationale:

The nurse should instruct the client to consume foods rich in potassium because furosemide, a loop diuretic, can lead to potassium depletion. By consuming potassium-rich foods, the client can help maintain proper electrolyte balance. Common potassium-rich foods include bananas, oranges, potatoes, and leafy greens. It is crucial to prevent hypokalemia, as it can result in adverse effects such as cardiac dysrhythmias and muscle weakness.

Choice B rationale:

Taking furosemide at bedtime is not necessary, and it is not a standard instruction. Furosemide is usually taken in the morning to avoid nocturia, as it increases urine output. This option does not address the primary concern of managing pulmonary edema and the potential electrolyte imbalances associated with furosemide use.

Choice C rationale:

Taking aspirin for headaches is not relevant to the client's condition of pulmonary edema or the use of furosemide. This choice does not provide valuable guidance to the client and may lead to unnecessary medication use.

Choice D rationale:

Expecting swelling in the hands and feet is not an appropriate instruction for a client with pulmonary edema. The goal of furosemide therapy is to reduce edema and fluid retention, not to expect or tolerate swelling. This option does not contribute to the client's well-being and recovery.

Choice A rationale:

Providing samples for sputum cultures every 6 weeks is not a necessary instruction for a client with pulmonary tuberculosis. Sputum cultures are typically performed at specific intervals to monitor the progress of treatment and assess for bacterial resistance. This information is essential for healthcare providers but not for the client's daily care and safety.

Choice B rationale:

Consuming alcohol in moderation while taking antituberculosis medications is not recommended. Alcohol can interact with these medications and reduce their effectiveness. It is essential to advise the client to avoid alcohol completely while on tuberculosis treatment to ensure the best possible outcome.

Choice C rationale:

Wearing a mask while out or around crowds of people is a crucial precaution to prevent the spread of tuberculosis, which is highly contagious. Tuberculosis is transmitted through the air when an infected person coughs or sneezes, making mask-wearing an effective measure to protect both the client and others. This instruction promotes the safety of the client and the community.

Choice D rationale:

Placing tissue soiled with respiratory secretions in a paper bag for later disposal is not a recommended practice. Infectious material should be properly disposed of in biohazard containers or bags designed for infectious waste. This instruction does not follow the standard safety protocols for managing infectious materials and is not in the best interest of the client's health.

Choice A rationale:

Withholding the digoxin dose for a decreased heart rate is the correct action. Digoxin is a medication used to treat heart failure, but it can lead to bradycardia (slow heart rate) as a side effect. In this scenario, the client's heart rate is already at 54 beats per minute, which is below the normal range. Administering digoxin could further slow the heart rate, potentially leading to dangerous bradycardia or heart block. Withholding the medication is essential to prevent this adverse event.

Choice B rationale:

Administering digoxin 0.25 mg is not the appropriate action in this case. The client's heart rate is already below the normal range, and giving the full dose of digoxin could further depress the heart rate and increase the risk of bradycardia. Withholding the medication is the safer course of action.

Choice C rationale:

Administering digoxin 0.125 mg is not recommended because the client's heart rate is already below the normal range. While a reduced dose may be considered in some situations, it's essential to withhold the medication and consult with the healthcare provider in this specific case, as the client's heart rate is significantly low.

Choice D rationale:

Withholding the digoxin dose for elevated BP is not the appropriate action. Digoxin is primarily used to treat heart failure by increasing the force of cardiac contractions. Elevated blood pressure is not an indication to withhold digoxin. The focus should be on addressing the low heart rate in this scenario. .

Choice A rationale:

The nurse should include the statement, "Lifelong treatment with this medication is necessary.”. This is because rifampin is often part of a multidrug regimen used to treat tuberculosis, and treatment typically lasts for several months, sometimes up to a year. It is crucial for the client to understand the need for long-term treatment to ensure the successful eradication of the tuberculosis bacteria from their system.

Choice B rationale:

The statement, "The medication causes amenorrhea if taken along with an oral contraceptive," is not accurate. Rifampin is known to interact with oral contraceptives, decreasing their effectiveness, but it does not directly cause amenorrhea. The correct teaching should focus on the need for alternative or additional contraceptive methods while taking rifampin.

Choice C rationale:

The statement, "You should wear glasses instead of contacts while taking this medication," is not directly related to rifampin. Rifampin can cause certain ocular side effects, but it does not necessarily require the client to switch from contacts to glasses. This advice would depend on the individual's eye health and any specific concerns.

Choice D rationale:

The statement, "A yellow tint to the skin is an expected reaction to the medication," is incorrect. While rifampin can cause a harmless side effect of orange-red discoloration of body fluids, such as urine, sweat, and tears, it does not typically cause a yellow tint to the skin. The nurse should clarify this misconception with the client.

Choice A rationale:

The nurse should identify that the client needs liver function tests while taking pyrazinamide. Pyrazinamide is one of the drugs used to treat tuberculosis, and it is known to potentially cause hepatotoxicity (liver damage). Regular monitoring of liver function tests, including liver enzymes like ALT and AST, is essential to detect any liver-related issues early and ensure the client's safety during the medication therapy.

Choice B rationale:

Thyroid function studies are not typically necessary while a client is taking pyrazinamide. Pyrazinamide is not known to have a direct effect on thyroid function.

Choice C rationale:

Blood glucose levels do not need to be monitored specifically due to pyrazinamide therapy. Although some antituberculosis drugs may affect blood sugar levels, pyrazinamide is not a common culprit for such side effects.

Choice D rationale:

Gallbladder studies are not typically indicated while taking pyrazinamide. Pyrazinamide is not known to cause specific issues related to the gallbladder. Monitoring liver function is more critical due to its potential hepatotoxicity.

Choice A rationale:

The nurse should identify that an effective outcome of IV fluid replacement in a client with dehydration is an increase in urine output. Urine output of 200 mL in 4 hours indicates that the kidneys are responding to the IV fluid replacement, and the client is likely rehydrating. This suggests that the renal perfusion has improved, and the client's body is eliminating waste products properly.

Choice B rationale:

A heart rate of 104 beats per minute is not necessarily indicative of the effectiveness of IV fluid replacement. Heart rate may vary for various reasons, and it is not a specific parameter for assessing the response to hydration. Other factors, such as blood pressure, should be considered to evaluate cardiovascular status.

Choice C rationale:

Peripheral pulses of +1 are not a direct indicator of the effectiveness of IV fluid replacement. While improved hydration may lead to better peripheral perfusion, this assessment is somewhat subjective and may not accurately reflect the overall effectiveness of the treatment.

Choice D rationale:

A urine specific gravity of 1.04 is not indicative of the effectiveness of IV fluid replacement. A specific gravity of 1.004 is within the normal range (normal range: 1.005-1.030) and does not necessarily indicate hydration status. It is essential to focus on urine output and other objective parameters to assess the effectiveness of hydration therapy. .

Choice A rationale:

"Fresh fruits are good to include with meals.”. Including fresh fruits with meals is an excellent choice for a heart-healthy diet. Fresh fruits are rich in essential vitamins, minerals, and fiber, which can help lower blood pressure and reduce the risk of heart disease.

Choice B rationale:

"I will replace table salt with dried herbs.”. This is a good choice for reducing sodium intake. Dried herbs can add flavor to food without the need for table salt, which is high in sodium. Lowering sodium intake is crucial for individuals with hypertension to manage their condition and maintain a heart-healthy diet.

Choice C rationale:

"I can have a cola drink twice a day.”. This choice is incorrect. Consuming cola drinks, which are high in sugar and caffeine, is not advisable for individuals with hypertension. High sugar intake can contribute to weight gain and high blood pressure, while caffeine can temporarily raise blood pressure. Clients with hypertension should limit or avoid soda consumption.

Choice D rationale:

"I can eat frozen juice bars for a snack.”. Frozen juice bars can be a healthier alternative to high-calorie, sugary snacks. However, the specific content of these bars should be considered. If they contain added sugars or high levels of sodium, it may not be the best choice. Clients with hypertension should focus on snacks that are low in added sugars and salt.

Choice A rationale:

"Pitting edema of the lower legs.”. Pitting edema is a common sign of congestive heart failure (CHF), and it often occurs bilaterally in the lower extremities. While this is a potential finding in left-sided heart failure, it is not specific to it.

Choice B rationale:

"Jugular venous distention.”. Jugular venous distention (JVD) is more indicative of right-sided heart failure or elevated central venous pressure. It is not a typical finding in left-sided heart failure.

Choice C rationale:

"Shortness of breath while lying down.”. This is a classic symptom of left-sided heart failure, known as orthopnea. When the patient lies flat, fluid that has accumulated in the lungs can lead to difficulty breathing. Patients with left-sided heart failure often find relief by sleeping with their upper body elevated.

Choice D rationale:

"Right upper quadrant pain.”. Right upper quadrant pain is not a typical finding in left-sided heart failure. It may be associated with issues related to the liver or gallbladder but is not directly related to heart failure.

Choice A rationale:

"Dull, aching calf pain.”. While dull, aching calf pain can be a symptom of deep vein thrombosis (DVT), it is not specific enough on its own to confirm the presence of a thrombus. Other conditions, such as muscle strain or injury, can also cause calf pain.

Choice B rationale:

"Positive Kernig's sign.”. Kernig's sign is typically associated with meningitis and is not relevant to the assessment of a thrombus.

Choice C rationale:

"Soft, pliable calf muscle.”. A soft and pliable calf muscle is not indicative of a thrombus. In fact, DVT is more likely to cause swelling and hardness in the affected calf due to the formation of a clot within the blood vessel.

Choice D rationale:

"Positive Homan's sign.”. A positive Homan's sign, which is elicited when dorsiflexion of the foot causes pain in the calf, can be a sign of a deep vein thrombosis (DVT). However, it is important to note that the Homan's sign is not considered a highly reliable diagnostic test for DVT, and other assessments and diagnostic tests, such as ultrasound, are typically used to confirm the presence of a thrombus.

Choice A rationale:

Administer IV morphine. Administering IV morphine may be necessary for pain management in a client with a pulmonary embolism. However, pain relief should not take precedence over ensuring the patient's oxygenation and cardiovascular stability. Oxygen therapy is the top priority to address hypoxia and prevent further deterioration. Once oxygenation is secured, pain management can be considered.

Choice B rationale:

Start an IV infusion of lactated Ringer's. Initiating an IV infusion of lactated Ringer's solution may be important for maintaining hydration and electrolyte balance in a patient with a pulmonary embolism. However, this is not the top priority when a client is at risk of or experiencing a pulmonary embolism. Ensuring oxygenation and cardiovascular stability takes precedence. Once the patient is stable, intravenous fluids can be administered if needed.

Choice D rationale:

Initiate cardiac monitoring. Initiating cardiac monitoring is important in assessing the patient's cardiac rhythm and identifying any dysrhythmias or changes that may occur due to the pulmonary embolism. While this is a vital step, it is not the highest priority when the client is in a state of hypoxia and respiratory distress. Oxygen therapy should be the first intervention to address the immediate threat to the patient's life.

Choice A rationale:

Heart rate 50/min. A heart rate of 50/min is within the normal range for many adults, and it is not an indication to withhold atenolol. In fact, atenolol is often prescribed to lower heart rate in individuals with conditions such as hypertension or arrhythmias. Therefore, a heart rate of 50/min should not be a reason to withhold atenolol.

Choice B rationale:

Respiratory rate 18/min. A respiratory rate of 18/min is within the normal range for adults and does not indicate a need to withhold atenolol. Atenolol primarily affects heart rate and blood pressure, not respiratory rate.

Choice C rationale:

Oxygen saturation 95%. An oxygen saturation of 95% is generally within the normal range, and it is not a reason to withhold atenolol. Atenolol's primary action is on the cardiovascular system, and it does not directly impact oxygen saturation.

Choice D rationale:

Blood pressure 160/94 mm Hg. A blood pressure of 160/94 mm Hg is elevated and exceeds the normal range for blood pressure. Atenolol is often prescribed to lower blood pressure, so in this case, it may be appropriate to withhold the medication. The elevated blood pressure could potentially lead to adverse effects, and withholding atenolol allows for further evaluation and appropriate management of the hypertension.

Choice A rationale:

Facial flushing. Facial flushing is not typically associated with atelectasis. Atelectasis is the collapse of a portion of the lung, which can lead to decreased oxygenation and respiratory distress but does not directly cause facial flushing. Flushing may be related to other factors such as fever or allergic reactions.

Choice B rationale:

Dry cough. A dry cough can be a common symptom of atelectasis. As the lung tissue collapses and airways become obstructed, it can lead to irritation and a dry, non-productive cough as the body attempts to clear the airway. So, a dry cough is an expected finding in a client with atelectasis.

Choice C rationale:

Decreasing respiratory rate. A decreasing respiratory rate is not typically associated with atelectasis. In fact, atelectasis often leads to an increased respiratory rate as the body tries to compensate for the reduced oxygen exchange. The patient may experience tachypnea (rapid breathing) as a result.

Choice D rationale:

Increasing dyspnea. Increasing dyspnea is a common and expected finding in a client with atelectasis. As lung tissue collapses and oxygen exchange is compromised, the patient will likely experience worsening shortness of breath. This is a concerning symptom and should be closely monitored, as it may indicate a need for intervention to improve lung expansion and oxygenation.

Choice A rationale:

Tolerance to nitroglycerin is not indicated by the presence of a headache. Nitroglycerin is a vasodilator used to relieve angina, and headaches can be a common side effect.

Choice B rationale:

Allergic reactions to nitroglycerin are rare, and a headache is not a typical symptom of an allergy to this medication.

Choice C rationale:

"A headache is a common adverse effect of this medication, but it will probably occur less often over time.”. This is the correct response. Nitroglycerin commonly causes headaches due to its vasodilatory effects. Patients often experience this side effect initially, but it tends to improve or occur less frequently with continued use. The nurse should educate the client about this and reassure them that the headaches should diminish over time.

Choice D rationale:

Anxiety may exacerbate chest pain, but it is not the likely cause of the headache. It is important to address the headache as a potential side effect of the medication.