A nurse is caring for a client receiving intravenous nitroglycerin. Which of the following assessments should the nurse prioritize?
Blood pressure
Respiratory rate
Oxygen saturation
Blood glucose levels
The Correct Answer is A
A) Correct. Nitroglycerin is a vasodilator primarily used to reduce angina and improve cardiac blood flow. Monitoring the client's blood pressure is crucial to assess the medication's effectiveness and prevent hypotension, a potential adverse effect. Nitroglycerin can cause significant vasodilation, leading to a drop in blood pressure, and the nurse should closely monitor the client's blood pressure during therapy.
B) Incorrect. Although monitoring respiratory rate is important, it is not the priority assessment when caring for a client receiving intravenous nitroglycerin.
C) Incorrect. Oxygen saturation should be monitored for clients receiving nitroglycerin, but it is not the priority assessment in this scenario.
D) Incorrect. Blood glucose levels are not directly affected by nitroglycerin and do not require prioritization in this case.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Correct. Digoxin is a cardiac glycoside, and hypokalemia increases the risk of digoxin toxicity. A serum potassium level of 3.2 mEq/L indicates hypokalemia and requires immediate nursing intervention. Hypokalemia can potentiate the effects of digoxin on cardiac conduction, leading to dysrhythmias.
B) Incorrect. A heart rate of 60 beats per minute is within the expected range for a client taking digoxin, as it is commonly used to control heart rate in certain cardiac conditions.
C) Incorrect. A systolic blood pressure of 100 mmHg may be within an acceptable range for a client with heart failure, depending on their baseline blood pressure and symptoms. It does not require immediate nursing intervention.
D) Incorrect. A digoxin level of 1.2 ng/mL is within the therapeutic range for digoxin. It does not require immediate nursing intervention.
Correct Answer is B
Explanation
B) Correct. ACE inhibitors can cause hyperkalemia as a side effect by inhibiting aldosterone secretion. Therefore, the nurse should prioritize assessing serum potassium levels regularly to monitor for hyperkalemia. This is particularly important in clients with pre-existing renal impairment or those taking other medications that can increase potassium levels.
A) Incorrect. ACE inhibitors do not directly affect blood glucose levels, although they may indirectly influence glycemic control in clients with diabetes.
C) Incorrect. Serum creatinine levels should be monitored regularly in clients receiving ACE inhibitors, as these medications can affect renal function. However, assessing serum potassium levels is a higher priority in this scenario.
D) Incorrect. White blood cell count is not directly related to ACE inhibitor therapy and does not require prioritization in this case.
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