What is the answer for this?

MyMystudentRN · Mar 9, 2012

first ones that stuck to me were A and C

MadpeysRN · Mar 9, 2012

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

a

you should always check your baseline and compare to see if it's higher or lower

maybe not c-was there a change? you wouldn't know unless you did a and the question doesnt say there was a change. the nursing action should be a

b-requires a dr's order and d is respiratory

just my 2 cents, if this was my test question-i would pick a, and if it was a and c i would argue it.

MadpeysRN · Mar 9, 2012

I am conflicted about C because what was the change? was it normally lower and is going up? Is it dropping, you don't know-it doesn't say. I am guessing-maybe there was no change-maybe it was 87/50 15 minutes ago as well. so I would def go with b,c, and d are distractors. yes you would nofity if there was a change-but the question doesnt say there was..... IMO

sapphire18 · Mar 9, 2012

I am conflicted about C because what was the change? was it normally lower and is going up? Is it dropping, you don't know-it doesn't say. I am guessing-maybe there was no change-maybe it was 87/50 15 minutes ago as well.....IMO

I agree with this, however you would not administer nitro to someone in the first place if their BP was only 87/50.

alpha omega · Mar 9, 2012

In the real world, it depends on the care setting. This happened to my nursing home patient.

He was not on IV, he just woke up in the middle of the night with chest pain. I checked his bp before giving the ntg and it was normal. However, the ntg did not relieve the chest pain, but his bp dropped, so I couldn't give him a second dose. I 911'ed him out to the hospital. It was an mi. He was treated in the hospital, recovered and sent back to us a few days later.

Amanda.RN · Mar 9, 2012

Definitely A & C.

ADN2B · Mar 9, 2012

B & C, hypovolemia lowers blood pressure and notify HCP of the life-threatening change of this vital sign.

0402 · Mar 10, 2012

Who said he's hypovolemic? Yes, this can be a cause of low BP, but there are many others. Nitro isn't going to make him hypovolemic; decreased BP is most likely an effect of the med. Before you increase anyone's IVF, what other conditions do they have? There are other ways to increase BP. Looking at trends is always appropriate and informing the MD of the change is, as well. I know it's not there, but I would also want to know if they are symptomatic.

RnfromUK · Mar 10, 2012

C = Passing the buck according to Kaplan so C is out.... I say A and B. Coughing and Deep breathing will not help the BP go up. Nitro is well known for making the BP drop. When we administer it we should be watching the BP closely anyway. :)

reginakrys · Mar 10, 2012

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 answer a, b, and c.

a = compare with baseline.

b = helps bring bp up, even though it wasn't stated that the cause is hypovolemia. also, our instructor taught us that in nclex, it is a perfect world, and you have all the resources to do everything you can, including doctor's orders.

c = do this after a, if there is a significant change.