NCLEX Practice Test

What is the appropriate nursing action for a client with unstable angina who reports a new dull, throbbing headache after 5 minutes on a nitroglycerin IV infusion?

1. Decrease the infusion rate and reassess the client’s report of pain

2. Document the finding and administer prescribed acetaminophen

3. Notify the health care provider and request a CT scan of the head

4. Stop the infusion immediately and notify the health care provider

The correct answer is: Decrease the infusion rate and reassess the client’s report of pain

The appropriate nursing action for a client experiencing a new dull, throbbing headache after the initiation of a nitroglycerin IV infusion is to decrease the infusion rate and reassess the client's report of pain. Nitroglycerin is a vasodilator commonly used to relieve angina by reducing myocardial oxygen demand. However, a common side effect of nitroglycerin can include headaches due to the dilation of cerebral blood vessels. By reducing the infusion rate, the nurse can mitigate the side effect while still providing the necessary treatment for unstable angina. Reassessing the headache after the adjustment allows for continued monitoring of the client's symptoms and effectiveness of pain control. This gradual approach helps in managing potential side effects without abruptly stopping the treatment, which might compromise the management of the angina. Other choices could involve immediate actions that may not be the best first step given the context of nitroglycerin's known side effects.