The nurse administers IV nitroglycerin to a client diagnosed with an acute myocardial infarction. In evaluating the effectiveness of this intervention, the nurse should monitor for:

decrease in heart rate.

relief of chest pain.

decrease in cardiac dysrhythmias.

decrease in blood pressure.

Answer and Explanation

The Correct Answer is B

A. Decrease in heart rate: While nitroglycerin can sometimes cause reflex tachycardia (an increase in heart rate) as a compensatory mechanism in response to a decrease in blood pressure, its primary effect is on reducing myocardial oxygen demand through vasodilation. Although heart rate may decrease in some situations due to improved perfusion or as a secondary response to pain relief, a decrease in heart rate is not the most reliable or immediate indicator of effectiveness in this context. The relief of chest pain is a more direct measure of the drug's impact.

B. Relief of chest pain: Nitroglycerin works by dilating blood vessels, which reduces myocardial oxygen demand and improves blood flow to the heart, particularly in cases of acute myocardial infarction (MI). The primary therapeutic goal is to relieve chest pain (angina) and reduce the workload of the heart. Monitoring for relief of chest pain is the most direct and important indicator of the medication's effectiveness. If the chest pain decreases or resolves, it suggests that the medication is helping to alleviate the ischemia caused by the MI.

C. Decrease in cardiac dysrhythmias: Nitroglycerin is not primarily used to treat dysrhythmias, although improved perfusion and reduced myocardial oxygen demand may indirectly reduce the occurrence of dysrhythmias in some cases. However, a decrease in dysrhythmias is not a primary goal of nitroglycerin therapy, and the nurse should not primarily monitor for this outcome. Any dysrhythmias should be managed with other specific interventions if needed.

D. Decrease in blood pressure: Nitroglycerin's vasodilatory effect does lead to a reduction in blood pressure, particularly in patients with high blood pressure or in the context of a myocardial infarction. However, excessive hypotension can be dangerous and may lead to inadequate perfusion of vital organs. The nurse must monitor blood pressure closely to avoid hypotension, but a decrease in blood pressure is not the main goal of therapy. The primary objective is to relieve the chest pain associated with the MI. If blood pressure drops too low, it may indicate a need to adjust the dose or discontinue the nitroglycerin.

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Correct Answer is A

Explanation

A. Suction the client as needed: Suctioning is an essential nursing intervention for clients on mechanical ventilation to maintain effective ventilation. Ventilated clients are at risk for accumulating secretions in the airway, which can obstruct the endotracheal tube or tracheostomy, impairing ventilation and oxygenation. Regular or as-needed suctioning helps to clear secretions, ensuring that the airway remains patent and effective ventilation is maintained. This intervention directly supports the goal of maintaining optimal respiratory function and preventing complications such as atelectasis, pneumonia, or hypoxia.

B. Administer pantoprazole sodium IV: Pantoprazole is a proton pump inhibitor used to decrease stomach acid, typically to prevent stress ulcers in critically ill patients. While this is an important aspect of care for preventing gastrointestinal complications in ventilated patients, it does not directly support ventilation. Therefore, administering pantoprazole is not as directly related to ensuring effective ventilation as suctioning or other respiratory interventions.

C. Apply sequential compression device (SCD): While applying an SCD is important for preventing deep vein thrombosis (DVT) and promoting circulation in immobile patients, it does not directly address the client's ventilation or respiratory function. This intervention is more relevant for preventing venous thromboembolism, not for managing ventilation or airway clearance.

D. Perform oral care with chlorhexidine: Oral care with chlorhexidine is an important practice to reduce the risk of ventilator-associated pneumonia (VAP) and promote overall oral hygiene. It helps decrease the colonization of bacteria in the mouth and reduces the risk of infection. However, while oral care is an essential component of care for a ventilated patient, suctioning directly addresses the goal of effective ventilation by maintaining airway patency, making it the most immediate and relevant intervention for supporting ventilation.

A. hyperglycemia B. Urinary retention C. Respiratory failure D. Hypertension

Correct Answer is C

Explanation

A. Hyperglycemia:
Although hyperglycemia can occur as a result of stress or corticosteroid use during the treatment of GBS (such as in the case of plasma exchange or IV immunoglobulin (IVIG) therapy), it is not the primary complication associated with GBS. While hyperglycemia requires monitoring and management, respiratory failure is a more immediate and critical concern.

B. Urinary retention:
Urinary retention can occur in some clients with neurologic disorders like GBS, but it is not as life-threatening as respiratory failure. The autonomic nervous system, which controls bladder function, may be affected, but urinary retention is usually manageable with intermittent catheterization or other interventions. It does not carry the same immediate risks to life or organ function as respiratory failure.

C. Respiratory failure:
In Guillain-Barré syndrome (GBS), the immune system attacks the peripheral nervous system, which can lead to progressive muscle weakness and paralysis. The most significant and potentially life-threatening complication of GBS is respiratory failure. This occurs because the paralysis can affect the muscles involved in breathing, including the diaphragm and intercostal muscles, leading to impaired ventilation. As the weakness progresses, the client may become unable to maintain effective breathing, requiring mechanical ventilation. Monitoring for signs of respiratory distress (e.g., increasing work of breathing, tachypnea, decreased breath sounds, or a drop in oxygen saturation) is critical in GBS, especially during the acute phase of the disease.

D. Hypertension:
Hypertension may be seen in some cases of GBS, particularly during the early stages of the disease, due to the autonomic dysfunction that can result from nerve involvement. However, hypotension (low blood pressure) is more commonly associated with the autonomic dysfunction in GBS rather than hypertension. Regardless, respiratory failure remains the most urgent complication to monitor for in clients with GBS.

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The nurse administers IV nitroglycerin to a client diagnosed with an acute myocardial infarction. In evaluating the effectiveness of this intervention, the nurse should monitor for:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

To achieve the outcome of effective ventilation, which nursing intervention should be included in the plan of care for a client on a ventilator?

Correct Answer is A

Explanation

The nurse is caring for the client experiencing Guillain-Barre syndrome (GBS). It is most important for the nurse to monitor the client for which complication?

Correct Answer is C

Explanation

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