After administering nitroglycerin spray to a client experiencing angina, which action should the nurse implement next?

Compress the client's nares.

Observe for facial flushing.

Advise the client to rest.

Elevate the client's feet.

Answer and Explanation

The Correct Answer is C

A. Compress the client's nares: Compressing the nares is a technique used for nasal medication administration or controlling nosebleeds, not for sublingual or oral spray forms of nitroglycerin. This action is unrelated to nitroglycerin use for angina.

B. Observe for facial flushing: Facial flushing is a common side effect of nitroglycerin due to vasodilation. While it should be noted during monitoring, it is not the immediate next action after administration when addressing angina symptoms.

C. Advise the client to rest: Resting after nitroglycerin administration reduces myocardial oxygen demand, helping to relieve anginal pain more effectively. It also helps prevent hypotension and dizziness, which are common side effects of the medication.

D. Elevate the client's feet: Elevating the feet is typically done if hypotension occurs. It is not a standard next step immediately after giving nitroglycerin unless the client shows symptoms like syncope or significant blood pressure drops.

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Correct Answer is A

Explanation

A. Contact the healthcare provider (HCP) immediately if suicidal thoughts occur: Antidepressants like sertraline can increase the risk of suicidal thoughts, especially during the early stages of treatment. Immediate reporting of such thoughts is critical to ensure the client’s safety and prevent harm.

B. Contact the healthcare provider (HCP) immediately if muscle stiffness occurs: Although rare, muscle stiffness could signal serotonin syndrome if occurs with a constellation of symptoms including confusion, agitation, fever, sweating and tremors, not just stiffness. Suicidal ideation presents a more immediate and life-threatening risk in clients starting antidepressants and requires the highest priority.

C. Increase activity level to include a daily exercise routine: While exercise is beneficial for managing depression, it is supportive therapy and not the most urgent teaching point compared to recognizing and reporting suicidal ideation associated with antidepressant use.

D. Avoid processed meats, red wine, and Swiss cheese: This dietary restriction is necessary when taking monoamine oxidase inhibitors (MAOIs) to prevent hypertensive crises. Sertraline is a selective serotonin reuptake inhibitor (SSRI), so these dietary precautions are not required.

A. Use relaxation techniques to reduce excessive anxiety. B. Avoid alcohol and other sedatives while taking the medication. C. Move slowly from a sitting position to a standing position. D. Stop taking the medication if intended effect is not immediate.

Correct Answer is D

Explanation

A. Use relaxation techniques to reduce excessive anxiety: Incorporating non-pharmacological strategies such as relaxation exercises complements lorazepam therapy and can improve anxiety management. This statement reflects appropriate understanding and safe self-care practices.

B. Avoid alcohol and other sedatives while taking the medication: Lorazepam is a central nervous system depressant, and combining it with alcohol or other sedatives can lead to respiratory depression, increased sedation, and potentially life-threatening effects. This is an important and accurate precaution.

C. Move slowly from a sitting position to a standing position: Orthostatic hypotension and dizziness are common side effects of benzodiazepines like lorazepam. Changing positions slowly helps minimize the risk of falls, especially in older adults or those sensitive to the medication.

D. Stop taking the medication if intended effect is not immediate: Lorazepam has a relatively quick onset, but stopping it abruptly without consulting a healthcare provider is unsafe and may lead to withdrawal symptoms including increased anxiety, insomnia, tremors, and even seizures. Clients must understand that medication adjustments require medical guidance.

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After administering nitroglycerin spray to a client experiencing angina, which action should the nurse implement next?

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