The nurse administers sublingual nitroglycerine, a vasodilator, ...

[cnetterville]

The nurse administers sublingual nitroglycerine, a vasodilator, to a patient diagnosed with angina. When the patient's chest pain is not relieved, the nurse prepares to give another nitroglycerine tablet.
 
  What is the nurse's priority action prior to administering the next dose of medication?
  a. Notify the physician.
  b. Elevate the head of the bed.
  c. Measure the patient's blood pressure.
  d. Place the patient on a cardiorespiratory monitor.

Question 2

The nurse is planning care for an elderly patient diagnosed with end-stage heart failure and a nursing diagnosis of Decreased Cardiac Output secondary to ineffective left ventricular function.
 
  What outcome would the nurse plan for this patient to measure improvement in cardiac output?
  a. Brisk capillary refill in feet bilaterally.
  b. Heart rate within expected range
  c. Breath sounds clear with no shortness of breath
  d. Regular pulse rhythm

[orangecrush]

Answer to Question 1

C
It is most important at this time for the nurse to measure the patient's blood pressure because vasodilating medications can result in a significant drop in blood pressure. There would be no reason to notify the physician unless the patient does not respond by the third dose of nitroglycerine. Elevating the head of the bed would be contraindicated, especially if the patient develops hypotension from vasodilation. Although placing the patient on a monitor is indicated, this is not related to administering the patient's medication.

Answer to Question 2

C
Left-sided failure causes blood to back up into the lungs and can result in pulmonary edema; therefore, clear breath sounds with no shortness of breath would be an effective outcome. When the right ventricle is compromised by heart failure, venous return is slowed and peripheral edema results; however, this patient has left-sided failure. Medications to treat heart failure are meant to alter heart rate, so this would not be the best indicator of improvement in the patient's condition. A patient with heart failure may have a regular rhythm even before treatment, so this is not the best choice for an indication of improved cardiac output.

[cnetterville]

Thank you!

[orangecrush]

Always glad to help...