A nurse is providing teaching to a client who has angina and a new prescription for nitroglycerin tablets. Which of the following instructions should the nurse include in the teaching?

The nurse should first address the client’s oxygen saturation, followed by the client’s blood pressure.

Addressing the oxygen saturation is crucial because the client’s level has dropped significantly to 86%, indicating potential respiratory distress or hypoxia. Following that, the nurse should address the blood pressure, which has also dropped, indicating possible hemodynamic instability.

Let’s break down the case notes to understand why addressing the client’s oxygen saturation and blood pressure is critical:

Oxygen Saturation

• Initial Vital Signs (1200): The client’s oxygen saturation was 100% on 2 L oxygen via nasal cannula.
• Current Vital Signs (1220): The oxygen saturation has dropped to 86% on the same oxygen support.

This significant drop in oxygen saturation indicates that the client is not receiving adequate oxygen, which can lead to hypoxia. Hypoxia can cause severe complications, including organ damage. Therefore, improving oxygenation is the top priority.

Blood Pressure

• Initial Vital Signs (1200): The client’s blood pressure was 110/75 mm Hg.
• Current Vital Signs (1220): The blood pressure has decreased to 90/60 mm Hg.

The drop in blood pressure suggests that the client is experiencing hemodynamic instability, which could be due to several factors, including dehydration, blood loss, or a reaction to anesthesia. Low blood pressure can lead to inadequate perfusion of vital organs, which is why it needs to be addressed promptly after stabilizing the oxygen saturation.

Other Symptoms

• Muscle Rigidity: The client is experiencing painful muscle rigidity, which could be a sign of a serious condition like malignant hyperthermia, especially given the elevated temperature.
• Temperature: The client’s temperature has spiked to 40.2°C (104.4°F), indicating a possible infection or reaction.
• Heart Rate: The heart rate has increased to 125/min, which could be a compensatory response to low blood pressure and hypoxia.
• Nausea and Vomiting: The client has vomited twice, which could contribute to dehydration and electrolyte imbalance.

Conclusion

By addressing the oxygen saturation first, the nurse ensures that the client is receiving adequate oxygen, which is essential for all bodily functions. Following that, stabilizing the blood pressure is crucial to ensure proper perfusion and prevent further complications.

Choice A rationale
Elevated alanine aminotransferase (ALT) is an adverse effect of simvastatin therapy. Statins, including simvastatin, can cause liver damage, which is indicated by elevated liver enzymes such as ALT2.
Choice B rationale
Elevated troponin T is not typically associated with simvastatin therapy. Troponin T is a marker for cardiac muscle damage, not a common adverse effect of statins.
Choice C rationale
Elevated WBC count is not a known adverse effect of simvastatin therapy. An elevated WBC count usually indicates an infection or inflammation.
Choice D rationale
Elevated thyroid-stimulating hormone (TSH) is not associated with simvastatin therapy. TSH levels are related to thyroid function, not the effects of statins.