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 B

Explanation

A. Focal awareness seizure:
Focal awareness seizures (formerly known as simple partial seizures) involve abnormal electrical activity in a specific area of the brain. These seizures typically cause motor symptoms (such as jerking or twitching in one part of the body) or sensory disturbances (like tingling or visual changes), but the person remains fully aware during the episode. The client’s presentation of a temporary loss of awareness and blank stare is more consistent with an absence seizure than a focal awareness seizure, as focal seizures do not cause a loss of consciousness.

B. Absence seizure:
Absence seizures are a type of generalized seizure often seen in children. These seizures are characterized by a sudden, brief loss of awareness, typically lasting only a few seconds. During the episode, the child may exhibit a blank stare and seem unresponsive, often without any noticeable physical movements. These seizures are often mistaken for daydreaming or inattention, but they can be diagnosed with an EEG (electroencephalogram) showing characteristic patterns. This description matches the parents’ observations of occasional episodes of loss of awareness and a blank stare.

C. Transient ischemic attack (TIA):
A TIA, also known as a mini-stroke, involves temporary neurological symptoms due to a brief disruption in blood flow to the brain. However, TIAs usually last longer than the brief episodes of loss of awareness described in this case, and they are more likely to cause focal neurological not just a transient loss of awareness. Additionally, TIAs are much less common in children and are usually associated with other risk factors like cardiovascular disease or clotting disorders.

D. Tonic clonic seizure:
Tonic-clonic seizures (formerly known as grand mal seizures) involve generalized shaking or convulsions, loss of consciousness, and can last from 1 to 3 minutes. These seizures are usually much more dramatic and prolonged compared to the brief, absence-like episodes described here. While they do involve a loss of awareness, the physical manifestations (muscle stiffening and jerking) and duration are distinctively different from the blank stare and brief loss of awareness typical of an absence seizure.

A. Wear a HEPA/N95 mask while providing care to the client B. Instruct the nursing assistant to wear a surgical mask when entering the client's room C. Ensure the client a in a positive pressure room D. Have the client wear a HEPA/N95 mask when outside of their room

Correct Answer is A

Explanation

A) Wear a HEPA/N95 mask while providing care to the client:
Tuberculosis (TB) is a highly contagious airborne disease, and healthcare workers caring for patients with active TB must wear a HEPA/N95 mask to protect themselves from inhaling the bacteria. These specialized masks filter out airborne particles, including Mycobacterium tuberculosis, which can be spread through droplets when the patient coughs, sneezes, or talks. Wearing an N95 mask is an essential part of airborne precautions in the care of TB patients.

B) Instruct the nursing assistant to wear a surgical mask when entering the client's room:
A surgical mask does not offer adequate protection against airborne pathogens like the tuberculosis bacteria. While surgical masks can block large droplets, they do not filter out smaller, airborne particles, such as those from TB. N95/HEPA masks are necessary for anyone entering the room of a patient with active tuberculosis, including nursing assistants, to ensure they are protected from inhaling infectious particles.

C) Ensure the client is in a positive pressure room:
A positive pressure room is typically used for patients who are immunocompromised, such as those with neutropenia or undergoing organ transplants, to prevent infection from the environment. However, negative pressure rooms are required for patients with airborne diseases like tuberculosis. A negative pressure room ensures that air flows into the room but does not leave, containing any airborne pathogens and preventing their spread to other areas of the facility.

D) Have the client wear a HEPA/N95 mask when outside of their room:
If the client with active tuberculosis needs to leave their room for medical procedures or testing, they should wear a HEPA/N95 mask to prevent spreading the bacteria to others through airborne transmission. This helps limit exposure to other individuals, as TB can be transmitted by airborne particles.

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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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