NCLEX-PN

Category - Pharmacological Therapies

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A nurse administers nitroglycerin to a client complaining of substernal chest pain. After the administration of the drug, which of the following actions should be the nurse’s priority?

Raise the side rails
Obtain the client’s blood pressure measurement
Assist in the low-Fowler’s position
Administer oxygen

Explanation

Answer: A - Dizziness is a potential side effect of nitroglycerin. The nurse has to ensure the safety of the client by raising the side rails and by staying close to the client. The other options are appropriate, but client safety should be the nurse’s priority. The nurse should also determine whether the medication relieves the chest pain.

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