The nurse is caring who presented with unstable angina. Before giving the client, a dose of sublingual nitroglycerin, which action should the nurse take?

Auscultate the client’s apical pulse for a full minute

Advise the client that vomiting is primary side effect

Check the client’s blood pressure

Obtain a STAT chest X-ray

Answer and Explanation

The Correct Answer is C

A. Auscultate the client’s apical pulse for a full minute:
While auscultating the apical pulse is important for certain cardiovascular conditions, it is not the primary action needed before administering sublingual nitroglycerin. The nurse's main priority is to assess the patient's blood pressure, as nitroglycerin can cause significant hypotension (a drop in blood pressure), and it is important to ensure the patient’s blood pressure is adequate before administration. If the blood pressure is too low, nitroglycerin should not be given.

B. Advise the client that vomiting is a primary side effect:
Vomiting is not a primary or common side effect of sublingual nitroglycerin. Nitroglycerin is more likely to cause headaches, dizziness, flushing, and hypotension. While it’s helpful to inform the patient about possible side effects, advising them that vomiting is a primary side effect could cause unnecessary concern or confusion.

C. Check the client’s blood pressure:
This is the correct action. Nitroglycerin works by dilating blood vessels, which can lower blood pressure. Before administering sublingual nitroglycerin, it is essential to check the client's blood pressure. If the client is hypotensive or has low blood pressure, nitroglycerin should be withheld, as it could further decrease blood pressure and worsen the patient’s condition. This is the priority nursing action to ensure the patient’s safety.

D. Obtain a STAT chest X-ray:
Obtaining a chest X-ray is not a priority action for a client with unstable angina before administering nitroglycerin. Chest X-rays are more useful for diagnosing conditions like pneumonia, pneumothorax, or other structural issues of the chest, but they are not immediately needed in the management of unstable angina. The most immediate concern is assessing the patient’s blood pressure before administering nitroglycerin.

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Correct Answer is A

Explanation

A) Pernicious anemia:
Vitamin B12 injections are most commonly used to treat pernicious anemia, which is caused by a deficiency in vitamin B12 due to an inability to absorb the vitamin from the gastrointestinal tract. This condition is often associated with a lack of intrinsic factor, a protein required for vitamin B12 absorption. As a result, the body cannot make enough healthy red blood cells, leading to anemia. The treatment of pernicious anemia typically involves lifelong vitamin B12 injections, making this the correct answer.

B) Hemolytic anemia:
It is not typically treated with vitamin B12 injections. Instead, hemolytic anemia may require treatments that address the underlying cause of red blood cell destruction, such as corticosteroids, immunosuppressive therapy, or splenectomy, depending on the type of hemolysis. Therefore, vitamin B12 would not be the primary treatment for this type of anemia.

C) Iron deficiency anemia:
It is typically treated with iron supplements, either orally or intravenously, rather than vitamin B12. While both conditions cause anemia, the treatment for iron deficiency anemia is not vitamin B12, so this is not the correct choice.

D) Aplastic anemia:
This condition is usually treated with treatments such as bone marrow stimulants, blood transfusions, or bone marrow transplantation, rather than vitamin B12. Vitamin B12 supplementation would not be indicated for the treatment of aplastic anemia.

A. Instruct the patient to swallow the medication with the head tilted backwards B. Place the medication in the backwards in the back of the mouth on the affected side C. Evaluate the patient’s ability to swallow D. Provide the patient with thickened liquids

Correct Answer is C

Explanation

A) Instruct the patient to swallow the medication with the head tilted backwards:
Tilting the head backward while swallowing may worsen the patient's ability to swallow, especially if they are experiencing facial droop and slurred speech. This position could increase the risk of aspiration or choking. A safer approach involves evaluating the patient’s swallowing ability before giving any oral medications.

B) Place the medication in the back of the mouth on the affected side:
While placing the medication on the unaffected side might seem like an alternative to help with swallowing, it is still important to assess the patient's swallowing ability first. If the patient has difficulty swallowing due to neurological deficits, placing the medication on the affected side could increase the risk of aspiration, leading to complications such as pneumonia.

C) Evaluate the patient’s ability to swallow:
Evaluating the patient's ability to swallow is the most important initial action. Facial droop and slurred speech can indicate potential dysphagia or difficulty swallowing, which could lead to aspiration if medications are given orally without further assessment. The nurse must determine if the patient can swallow safely before administering any oral medications, including aspirin, to prevent complications.

D) Provide the patient with thickened liquids:
Thickened liquids may be helpful for patients with known dysphagia, but this approach is not suitable in this case because the first priority is assessing the patient's swallowing ability. Giving thickened liquids without evaluating swallowing could increase the risk of aspiration if the patient is unable to manage liquids safely. An evaluation should precede any interventions like thickening liquids.

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The nurse is caring who presented with unstable angina. Before giving the client, a dose of sublingual nitroglycerin, which action should the nurse take?

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