A nurse is caring for a client who is on warfarin therapy for atrial fibrillation. The client's INR is 5.2. Which of the following medications should the nurse prepare to administer?

Choice A reason: Taking this medication with 8 ounces of water is not necessary. Sublingual nitroglycerin tablets are designed to dissolve under the tongue and be absorbed quickly into the bloodstream. Drinking water may interfere with the absorption and effectiveness of the medication.

Choice B reason: Taking one tablet at the first indication of chest pain is the correct instruction. Sublingual nitroglycerin tablets are used to relieve anginal pain by dilating the coronary arteries and improving blood flow to the heart. The client should place one tablet under the tongue as soon as chest pain occurs and wait for it to dissolve.

Choice C reason: Taking one tablet every 15 minutes during an acute attack is not the correct instruction. Sublingual nitroglycerin tablets have a short duration of action and may not provide adequate relief for a prolonged anginal attack. The client should follow the rule of three: take one tablet every 5 minutes for up to three doses. If the pain is not relieved after three doses, the client should call 911 or seek emergency medical attention.

Choice D reason: Taking this medication after each meal and at bedtime is not the correct instruction. Sublingual nitroglycerin tablets are not used for the prevention of angina. They are only used for the treatment of acute anginal episodes. Taking this medication regularly may cause tolerance and reduce its effectiveness.

Choice A reason: Ototoxicity is not a severe reaction to propranolol, but it may occur with some other medications, such as aminoglycosides, loop diuretics, or salicylates. Ototoxicity may damage the inner ear or the auditory nerve and cause hearing loss, tinnitus, or vertigo. The nurse should assess the client's medication history and monitor the client's hearing function.

Choice B reason: Hypokalemia is not a severe reaction to propranolol, but it may occur with some other medications, such as thiazide diuretics, corticosteroids, or insulin. Hypokalemia may cause muscle weakness, cramps, arrhythmias, or cardiac arrest. The nurse should advise the client to eat foods rich in potassium, such as bananas, oranges, or potatoes, and to have regular blood tests to check the electrolyte levels.

Choice C reason: Tachycardia is not a severe reaction to propranolol, but it may be a sign of overdose, withdrawal, or rebound effect. Propranolol is a beta-blocker that lowers the heart rate and blood pressure by blocking the effects of epinephrine and norepinephrine. Propranolol may cause bradycardia, not tachycardia, as a side effect. The nurse should monitor the client's vital signs and advise the client to take the medication as prescribed and not to stop it abruptly.

Choice D reason: Postural hypotension is a severe reaction to propranolol, as it may cause dizziness, fainting, or falls. Postural hypotension occurs when the blood pressure drops significantly when the client changes position, such as from lying to sitting or standing. Propranolol may cause postural hypotension by reducing the vascular tone and the cardiac output. The nurse should instruct the client to change position slowly and to report any symptoms of postural hypotension to the provider.