A nurse in a health clinic is caring for a client.

Exhibits

Select 1 condition and 1 client finding to fill in each blank in the following sentence.

The client is at risk for developing 

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due to 

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A Nitroglycerin is a vasodilator that helps relieve angina by dilating blood vessels and increasing blood flow to the heart muscle. It is typically the first-line medication for acute angina attacks. Administering nitroglycerin promptly can help alleviate the client's pain and prevent progression to a myocardial infarction (heart attack).

B. Aspirin is often administered to clients with suspected myocardial ischemia or infarction because it inhibits platelet aggregation, which can reduce the risk of clot formation and further occlusion of coronary arteries. It is typically given early in the management of acute coronary syndrome to prevent clotting complications.

C. While monitoring blood pressure is important in clients with acute angina, especially to assess for hypotension which could indicate cardiogenic shock, it is not the first action. Immediate pain relief and prevention of further ischemic damage take precedence over blood pressure measurement.

D. IV access is important for administering medications and fluids if needed, but it is not the first priority unless the client's condition warrants immediate IV medication administration (such as in severe pain or impending myocardial infarction).

B. The appropriate action for a nurse to take would be to check for air leaks in the system. This can be done by clamping the tubing momentarily to see if the bubbling stops, which would suggest the presence of a leak.

A The drainage system should always be kept below the level of the chest and should not be raised or emptied unless specifically indicated.

C. Emptying the collection chamber is typically unnecessary unless it is nearing full capacity. Continuous bubbling in the water seal chamber does not indicate that the collection chamber needs immediate emptying.

D. Squeezing the tubing can disrupt the functioning of the drainage system and is not recommended. Drainage should flow passively into the collection chamber without external manipulation.