A nurse is teaching a group of nurses about the administration of nitroglycerin. Which of the following routes of administration provides the most rapid onset for the client?

Choice A: “I have a tight sensation in my lower leg when I forget to put my feet up.” This statement may indicate the presence of edema, which is common in cirrhosis due to hypoalbuminemia and sodium retention. However, it is not as immediately concerning as other symptoms because it can often be managed with diuretics and compression. It is important to monitor for worsening edema, as it can lead to increased discomfort and risk of skin breakdown.

Choice B: “I can’t button my pants anymore because my belly is so swollen.” This statement is concerning because it suggests the development of ascites, which is the accumulation of fluid in the peritoneal cavity, causing abdominal swelling. Ascites can lead to abdominal discomfort, difficulty breathing, and is a sign of advanced liver disease with significant portal hypertension. It requires medical evaluation and management, which may include paracentesis (removal of fluid), diuretics, and sodium restriction. Cirrhosis is a late stage of scarring (fibrosis) of the liver caused by many forms of liver diseases and conditions, such as hepatitis and chronic alcoholism. Portal hypertension is an increase in the blood pressure within a system of veins called the portal venous system. Veins from the stomach, intestine, spleen, and pancreas merge into the portal vein, which then branches into smaller vessels and travels through the liver.

Choice C: “I’m very constipated and have been straining during bowel movements.” While constipation is uncomfortable and can indicate dietary issues or side effects from medication, it is not typically a direct complication of cirrhosis or portal hypertension. However, straining during bowel movements can increase the risk of bleeding from esophageal varices if they are present, so it is important to manage constipation to prevent potential complications.

Choice D: “When I sleep, I have to sit in a recliner so that I can breathe more easily.” This statement indicates orthopnea, which can be associated with ascites or pleural effusions (fluid in the lungs), both of which can occur in the setting of cirrhosis and portal hypertension. While this symptom is concerning and affects the client’s quality of life, it is generally less concerning than the development of ascites, as it can be managed with adjustments in sleeping position and medical management of the underlying fluid accumulation.

Choice A: Fever and chills Fever and chills are not typically associated with the abrupt cessation of TPN. These symptoms are more commonly related to infections or inflammatory processes in the body. While infections can be a complication of TPN due to the invasive nature of the therapy, they are not a direct result of the discontinuation of the infusion. Total Parenteral Nutrition (TPN) is a method of feeding that bypasses the gastrointestinal tract. Fluids are given into a vein to provide most of the nutrients the body needs. The sudden stop in the infusion of TPN can lead to a rapid drop in blood sugar levels, known as hypoglycemia, because the body has become accustomed to the continuous influx of glucose from the TPN solution.

Choice B: Hypertension and crackles Hypertension (high blood pressure) and crackles (sounds heard on lung auscultation indicative of fluid in the air spaces) are not expected clinical manifestations due to the stopping of TPN. These symptoms are more commonly associated with cardiovascular and pulmonary conditions, respectively.

Choice C: Excessive thirst and urination Excessive thirst and urination could be symptoms of hyperglycemia (high blood sugar), which might occur if TPN is infused too quickly or if the patient has an increased insulin requirement. However, these are not the immediate concerns when TPN is abruptly stopped.

Choice D: Shakiness and diaphoresis Shakiness and diaphoresis (sweating) are common signs of hypoglycemia, which can occur if TPN is stopped suddenly. The body may have been receiving a steady supply of glucose from the TPN, and a sudden halt can cause blood sugar levels to drop quickly. This can lead to symptoms such as weakness, shakiness, sweating, and even confusion or loss of consciousness if not addressed promptly. When TPN is abruptly discontinued, the nurse should monitor the client for signs of hypoglycemia, including shakiness and diaphoresis. It is important to restart the TPN infusion as soon as possible or provide an alternative source of glucose to prevent hypoglycemia and its potential complications.