# A 65-year-old male client with chronic stable angina arrives at the ED with substernal chest pain. EMS administered sublingual nitroglycerin 0.4 mg × 2 doses en route. On arrival, BP is 68/40, HR 124, dizzy and diaphoretic. He admits taking sildenafil 100 mg approximately 12 hours ago. Which action by the nurse takes priority? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=374936&lang=en > language: en > subject: Adverse Effects/Contraindications/Interactions > category: PA ## Question A 65-year-old male client with chronic stable angina arrives at the ED with substernal chest pain. EMS administered sublingual nitroglycerin 0.4 mg × 2 doses en route. On arrival, BP is 68/40, HR 124, dizzy and diaphoretic. He admits taking sildenafil 100 mg approximately 12 hours ago. Which action by the nurse takes priority? ## Option 1. Place the client in Trendelenburg position, initiate norepinephrine infusion at 0.05 mcg/kg/min and titrate to maintain MAP above 65 mmHg, insert a Foley catheter for urine output monitoring, and obtain a stat echocardiogram to evaluate for right ventricular infarction. 2. Given the chest pain persists, administer another dose of sublingual nitroglycerin 0.4 mg, and apply 2 L oxygen via nasal cannula; the sildenafil was taken 12 hours ago, so the risk of interaction is minimal. 3. Place the client supine with legs elevated, establish two large-bore IVs and start a rapid normal saline bolus per provider order, place him on continuous cardiac and BP monitoring, and notify the provider; do NOT give any further nitrates. **✔ Correct answer** 4. Obtain a 12-lead ECG and serial cardiac enzymes, administer aspirin 325 mg chewed, start oxygen at 2 L/min via nasal cannula, and activate the cardiac catheterization lab; the hypotension is likely due to the underlying ischemic event and will resolve with treatment. **Correct answer: 3** ## Explanation Nitrate + PDE5 inhibitor — life-threatening hypotension PDE5 inhibitors (sildenafil, tadalafil, vardenafil) potentiate the vasodilatory effect of nitrates by blocking the breakdown of cGMP, producing profound, refractory hypotension that can lead to MI, stroke, and death. The combination is contraindicated within 24 hours of sildenafil/vardenafil and 48 hours of tadalafil. This client has a clear medication history and is now hemodynamically unstable. Priority interventions: • Stop all nitrates immediately; do not administer additional NTG. • Supine position with legs elevated (modified Trendelenburg) to augment venous return. • Two large-bore IVs and rapid isotonic crystalloid bolus (1-2 L NS) per provider order. • Continuous ECG, BP, pulse oximetry; prepare for possible vasopressor (phenylephrine, norepinephrine) if fluid alone insufficient. • Notify provider; obtain serial troponins and 12-lead ECG (concomitant ACS possible). • Document medication reconciliation and add PDE5 + nitrate alert to chart. The combination is the cause of his hypotension; giving more sildenafil or more nitrate is dangerous, and discharge is not appropriate. ## In-depth explanation Clinical reasoning summary Nitrate + PDE5 inhibitor — life-threatening hypotension PDE5 inhibitors (sildenafil, tadalafil, vardenafil) potentiate the vasodilatory effect of nitrates by blocking the breakdown of cGMP, producing profound, refractory hypotension that can lead to MI, stroke, and death. The combination is contraindicated within 24 hours of sildenafil/vardenafil and 48 hours of tadalafil. This client has a clear medication history and is now hemodynamically unstable. Priority interventions: • Stop all nitrates immediately; do not administer additional NTG. • Supine position with legs elevated (modified Trendelenburg) to augment venous return. • Two large-bore IVs and rapid isotonic crystalloid bolus (1-2 L NS) per provider order. • Continuous ECG, BP, pulse oximetry; prepare for possible vasopressor (phenylephrine, norepinephrine) if fluid alone insufficient. • Notify provider; obtain serial troponins and 12-lead ECG (concomitant ACS possible). • Document medication reconciliation and add PDE5 + nitrate alert to chart. The combination is the cause of his hypotension; giving more sildenafil or more nitrate is dangerous, and discharge is not appropriate. ## Related questions - [A nurse is reviewing the morning lab results for an adult client receiving warfarin for at…](https://mymerci.kr/pages/nclex_q.php?qn_id=360515&lang=en) - [A client is admitted to the emergency department after ingesting an unknown amount of acet…](https://mymerci.kr/pages/nclex_q.php?qn_id=362720&lang=en) - [A client with chronic heart failure is prescribed metoprolol 25 mg orally twice daily. Bef…](https://mymerci.kr/pages/nclex_q.php?qn_id=362756&lang=en) - [A 28-year-old client with type 1 diabetes receives regular insulin 6 units and NPH insulin…](https://mymerci.kr/pages/nclex_q.php?qn_id=362792&lang=en) - [A client receives IV vancomycin 1 g every 12 hours for MRSA bacteremia. 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