The nurse administers a sublingual nitroglycerin tablet to a client with unstable angina. Which finding is most important for the nurse to report to the healthcare provider (HCP)?

Bilateral tinnitus when initially standing up.

Dizziness when rising from the bedside.

Hypotension with a systolic of 90 mm Hg.

Onset of headache after administration.

Answer and Explanation

The Correct Answer is C

A. Bilateral tinnitus when initially standing up: Tinnitus is not a common or serious adverse effect of nitroglycerin. While it may indicate another underlying issue, such as hypertension or ototoxicity, it is not immediately life-threatening.

B. Dizziness when rising from the bedside: Dizziness can result from the vasodilatory effects of nitroglycerin causing orthostatic hypotension. It is relatively common and usually managed with safety precautions and monitoring rather than immediate reporting.

C. Hypotension with a systolic of 90 mm Hg: A systolic blood pressure of 90 mm Hg is concerning after nitroglycerin administration, as the drug significantly lowers preload and can precipitate hemodynamic instability. This finding requires prompt HCP notification to prevent complications such as syncope or myocardial underperfusion.

D. Onset of headache after administration: Headache is a well-known and expected side effect of nitroglycerin due to cerebral vasodilation. While uncomfortable, it is generally benign and does not warrant immediate reporting unless it becomes severe or unrelenting.

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Free Nursing Study Resources

Correct Answer is ["A","B","E"]

Explanation

Agitation: Agitation may indicate hypoxia or reduced cerebral perfusion due to cardiac compromise. In a patient with chest pain and borderline hypoxia, it can be an early warning sign of clinical deterioration that requires follow-up.
Chest pain described as pressure tightness unrelieved by rest: Unrelieved chest pain lasting longer than 20 minutes is strongly suggestive of myocardial infarction rather than stable angina. Immediate cardiac workup and intervention are needed to prevent myocardial damage.
Pain rated 7/10: A moderate to severe pain rating in the chest warrants urgent evaluation, especially when consistent with cardiac characteristics like tightness and pressure. High pain intensity is often correlated with worsening ischemia.

A. Atrial and ventricular rates are 115 beats/minute B. There is a wide QRS complexes. C. The PP interval is regular. D. There is absence of P waves. E. The PR interval measures 0.12 seconds. F. The QRS complex measures 0.08 seconds.

Correct Answer is ["A","C","E","F"]

Explanation

A. Atrial and ventricular rates are 115 beats/minute: Sinus tachycardia is defined by a heart rate greater than 100 beats/minute with normal sinus rhythm. The atrial and ventricular rates remain equal and typically range between 100–150 beats/minute in sinus tachycardia.

B. There is a wide QRS complex: Wide QRS complexes (>0.12 seconds) are not typical of sinus tachycardia and suggest an abnormal ventricular conduction, such as bundle branch block or ventricular rhythm, which is not supported by the sinus origin in this case.

C. The PP interval is regular: Regular PP intervals indicate consistent atrial depolarization, which is a hallmark of sinus rhythms, including sinus tachycardia. This reflects a stable and predictable SA node discharge.

D. The PR interval measures 0.12 seconds: A normal PR interval ranges from 0.12 to 0.20 seconds, and in sinus tachycardia, the PR interval remains within this normal range despite the faster rate.

E. There is absence of P waves: P waves are present and upright in leads II, III, and aVF during sinus tachycardia. Absence of P waves would suggest an atrial arrhythmia such as atrial fibrillation, not sinus tachycardia.

F. The QRS complex measures 0.08 seconds: A narrow QRS complex (<0.12 seconds) confirms that ventricular depolarization is occurring through the normal conduction pathways, which is typical in sinus tachycardia.

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The nurse administers a sublingual nitroglycerin tablet to a client with unstable angina. Which finding is most important for the nurse to report to the healthcare provider (HCP)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","E"]

Explanation

Exhibits The client's electrocardiogram (ECG) strip reveals sinus tachycardia. Select the 4 characteristics that the nurse is likely to see in the ECG.

Correct Answer is ["A","C","E","F"]

Explanation

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