# The nurse is caring for a client with chest pain in the emergency department at 0750. Review the chart. Which prescription requires clarification with the provider before it is given? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=617264&lang=en > language: en > subject: Adverse Effects/Contraindications/Interactions > category: PPT ## Question The nurse is caring for a client with chest pain in the emergency department at 0750. Review the chart. Which prescription requires clarification with the provider before it is given? History Vitals Labs Orders Notes 61-year-old male. Type 2 diabetes, hypertension, former smoker. Aspirin intolerance listed as "stomach upset" (no hives or wheezing). Hemorrhoid bleeding 3 years ago, none since. Home meds: metformin, lisinopril, sildenafil 100 mg as needed. 0740: BP 138/84 mm Hg, HR 72/min regular, RR 18/min, SpO2 96% on room air, T 36.8 C. Weight 88 kg. 0745: High-sensitivity troponin I elevated. Platelets 162,000/mm3. Hemoglobin 13.1 g/dL. Creatinine 1.3 mg/dL (baseline 1.2). Glucose 188 mg/dL. Potassium 4.4 mmol/L. Aspirin 324 mg chewed now. Nitroglycerin 0.4 mg SL every 5 min up to 3 doses PRN chest pain. Heparin IV bolus and infusion per ACS weight-based protocol. Metoprolol tartrate 25 mg PO now. Hold metformin. 0735: Substernal pressure since 0630, 7/10. ECG: ST elevation in leads II, III, aVF; no ST elevation in right-sided leads. Lungs clear. Spouse reports the client took his "bedroom pill" at 2200 last night; bottle confirms sildenafil. 1 Aspirin 324 mg chewed by mouth now ✕ 2 Nitroglycerin 0.4 mg SL q5min PRN ✕ 3 Heparin IV bolus per ACS protocol ✕ 4 Metoprolol tartrate 25 mg PO now ✕ ## Explanation Sildenafil taken at 2200 is less than 10 hours old, and nitrates are avoided within 24 hours of sildenafil because the combination can cause profound, refractory hypotension, so the nitroglycerin order must be clarified. The aspirin intolerance is GI upset rather than allergy, the platelet count and remote hemorrhoid bleed do not contraindicate heparin, and HR 72 with BP 138/84 and clear lungs supports the beta-blocker. ## In-depth explanation Quick answer Nitroglycerin needs clarification because of recent sildenafil. Why this is correct The notes show sildenafil taken at 2200, under 10 hours before the order. PDE5 inhibitors and nitrates together cause severe, prolonged vasodilation and hypotension; nitrates are avoided for 24 hours after sildenafil. The BP is normal now, which is exactly why the danger is easy to miss. Easy analogy or mental picture Sildenafil opens the vessel doors; nitroglycerin opens them too. Together, the doors come off their hinges and the pressure falls out. Memory hook PDE5 inhibitor in the last 24 h (48 h for tadalafil) = NO nitrate. NCLEX decision rule For order clarification in a chart item, match each order with a specific chart finding; a finding that looks concerning must be a true contraindication to count. Why the other choices are wrong The aspirin order draws attention because of the listed "intolerance," but stomach upset is not an allergy and aspirin benefit in ACS outweighs it. Heparin tempts because of the old hemorrhoid bleed and a platelet count near the low-normal range, but neither is an active bleed or thrombocytopenia. Metoprolol tempts in an inferior MI, yet HR 72, BP 138/84, and clear lungs show no bradycardia, hypotension, or heart failure to prevent its use. References 1MedlinePlus: SildenafilSildenafil must not be combined with nitrates such as nitroglycerin because of severe hypotension 22025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary SyndromesNitrates are avoided after recent phosphodiesterase-5 inhibitor use; aspirin, anticoagulation, and beta-blockers are standard ACS therapy ## Clinical scenario Scenario A client with inferior STEMI took sildenafil at 2200 the night before and now has an order for sublingual nitroglycerin. ## Key concepts - **PDE5 inhibitor** — A drug such as sildenafil that relaxes vascular smooth muscle and interacts dangerously with nitrates. - **Inferior STEMI** — ST-elevation MI in leads II, III, and aVF, usually from right coronary artery occlusion. - **Drug intolerance** — An unpleasant non-immune side effect, different from a true allergic reaction. ## Related questions - [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. 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