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 D

Explanation

A. 2+ pedal edema bilaterally:
While 2+ pedal edema (a mild level of swelling in the feet and ankles) is concerning, it is not an immediate emergency in the context of hyponatremia. Edema can be seen in various conditions, including fluid retention associated with hyponatremia, but it does not require urgent intervention unless it is severe or worsening. This finding would warrant monitoring but does not require immediate action.

B. Blood pressure at 107/82:
A blood pressure reading of 107/82 mmHg is within normal limits, although on the lower end of the spectrum. This is not a concerning finding in this case and does not suggest a need for immediate intervention. The nurse should continue to monitor the client, but this blood pressure reading alone is not an emergency.
C. Urine output of 460 mL in 24 hours:
A urine output of 460 mL in 24 hours is low, indicating oliguria (decreased urine output), which can occur in cases of hyponatremia due to fluid retention. However, unless the urine output is worsening or associated with other signs of acute kidney injury or severe fluid overload, this finding alone does not require immediate intervention. It is something that should be monitored and further investigated.

D. Disorientation:
Disorientation in the elderly client with hyponatremia is a critical finding that requires immediate intervention. Hyponatremia can lead to cerebral edema (brain swelling), which results in altered mental status, including confusion, disorientation, or seizures. These symptoms indicate that the hyponatremia may be severe enough to affect neurological function and requires prompt correction to avoid further complications, such as coma or permanent brain damage. Immediate intervention to address the underlying cause of the hyponatremia and restore sodium balance is crucial.

A. Pernicious anemia B. Hemolytic anemia C. Iron deficiency anemia D. Aplastic anemia

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.

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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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