What is the answer for this?

I would say

B and C..

You should already check his BP before giving him the nitro, and coughin/deep breathing isn't going to bring his BP up.

the 65 year old client has been administered nitroglycerin for chest pain. the client's blood pressure 15 minutes after this administration is 87/50. what is the nursing action? select all that apply

a. compare the client's last bp prior to administering the drug

b. increase the drip rate on the normal saline iv

c. notify the provider of the change in vital signs

d. have the client cough and deep breathe

i would pick pick a (this is an assessment action) and c .

you need an order for b and d is a distractor.

I say A and C.

Sometimes I get tripped up by these types of questions, because I want to assume the patient is on NS, but no where does it state that, so normally, I would not pick it, but depending on the mood of the writer of Kaplan's questions, it could be right or wrong.

Anyway, my choices are A (need to know how much of a change and know trends) and C (obvious).

a, c, maybe (b)do we need a doctor order to increase NS? That needs to be done too. Good question!!

@Nurseadam

remember option a. did not say check BP it said compare. meaning you already have checked the prior BP and it needs to be compared with the current BP.

How long does it take to inform the doctor? If you are going to call the doctor anyways why risk increasind the fluid rate? To what rate will you increase it to?????????????

@ellord if this wasn't a SATA question. My only pick would be C. but A and C seems to be the best one and the other two seem to be distractors.

I would choose A and C

I would also choose B because i was told in NCLEX order that if an answer is there to give meds, you have the order because NCLEX is perfect world.

The client is in shock with BP systolic

OTOH some may say you need a doctors order.

It's a grey area but the numbers were given so I'd say ABC

What's the answer??