The nurse is caring for a patient diagnosed with asthma on a medical surgical unit. The nurse is concerned when the patient makes the following statement after completing their Albuterol nebulizer treatment:

Choice A reason: This is correct. Blood pressure is the most important vital sign to monitor after giving sublingual nitroglycerin to a client with chest pain. Nitroglycerin is a medication that dilates the blood vessels and lowers the blood pressure. This can relieve the chest pain caused by angina, which is a condition where the heart muscle does not get enough oxygen due to narrowed or blocked arteries. However, if the blood pressure drops too low, the client may experience dizziness, fainting, or shock. Therefore, the nurse should check the blood pressure before and after giving nitroglycerin and report any significant changes to the doctor.

Choice B reason: This is incorrect. Blood glucose levels are not directly affected by sublingual nitroglycerin. However, some clients with chest pain may also have diabetes, which is a risk factor for heart disease. Diabetes is a condition where the body cannot regulate the amount of sugar in the blood. High or low blood sugar levels can cause symptoms such as thirst, hunger, fatigue, blurred vision, or confusion. Therefore, the nurse should check the blood glucose levels of clients with diabetes and follow the doctor's orders for managing their blood sugar.

Choice C reason: This is incorrect. Body temperature is not directly affected by sublingual nitroglycerin. However, some clients with chest pain may also have a fever, which is a sign of infection or inflammation. Fever is a condition where the body's temperature rises above the normal range. Fever can cause symptoms such as sweating, chills, headache, or muscle ache. Therefore, the nurse should check the body temperature of clients with fever and follow the doctor's orders for treating their infection or inflammation.

Choice D reason: This is incorrect. Respiratory rate is not directly affected by sublingual nitroglycerin. However, some clients with chest pain may also have difficulty breathing, which is a sign of heart failure or lung disease. Difficulty breathing is a condition where the client cannot get enough air into or out of the lungs. Difficulty breathing can cause symptoms such as coughing, wheezing, or gasping. Therefore, the nurse should check the respiratory rate of clients with difficulty breathing and follow the doctor's orders for improving their oxygenation.

Choice A reason: This is incorrect. Polydipsia is excessive thirst, which is a symptom of hyperglycemia (high blood sugar), not hypoglycemia (low blood sugar). People with hyperglycemia lose fluid through frequent urination and become dehydrated, which makes them thirsty.

Choice B reason: This is correct. Shaking is a common sign of hypoglycemia. It occurs because the body releases adrenaline and other hormones to raise blood sugar levels. Adrenaline causes the muscles to tremble or shake.

Choice C reason: This is correct. Confusion is another common sign of hypoglycemia. It occurs because the brain does not get enough glucose, which is its main source of energy. Low blood sugar can impair cognitive functions, such as memory, attention, and judgment.

Choice D reason: This is incorrect. Tachycardia is a rapid heart rate, which can be a symptom of both hypoglycemia and hyperglycemia. However, it is not a specific or reliable indicator of low blood sugar, as it can also be caused by other factors, such as stress, anxiety, caffeine, or medication.

Choice E reason: This is incorrect. Polyuria is excessive urination, which is another symptom of hyperglycemia, not hypoglycemia. People with hyperglycemia have high levels of glucose in their blood, which draws water from the cells and increases urine output.