The nurse is caring for a client receiving IV nitroglycerin for chest pain. Which assessment finding requires immediate action?

Correct Answer: A

Rationale: Nitroglycerin dilates vessels, relieving angina but risking hypotension. BP of 90/60 mmHg indicates excessive drop, requiring immediate action (e.g., stopping infusion) to prevent shock. Heart rate of 80 and respiratory rate of 16 are normal. Pain at 2/10 shows efficacy. Hypotension's threat to perfusion aligns with nitroglycerin's effect, critical in chest pain where stability is key, making A the finding needing swift response.

Correct Answer: D

Rationale: Antilipemic agents are medications used to lower lipid levels in the blood, particularly cholesterol. These medications can have hepatotoxic effects, meaning they can potentially cause liver damage. Therefore, patients on antilipemic therapy need to be closely monitored for signs of liver dysfunction, such as elevated liver enzymes, jaundice, abdominal pain, or unexplained fatigue. Regular liver function tests are often conducted to ensure the liver is functioning properly while the patient is on this therapy. Monitoring for liver dysfunction is crucial to prevent complications and ensure the safety of the patient.

Correct Answer: A

Rationale: Albuterol is a medication commonly used to treat asthma and other respiratory conditions. It works by relaxing the muscles in the airways, allowing the air passages to widen and making it easier to breathe. This bronchodilation effect helps to relieve symptoms such as wheezing, shortness of breath, and chest tightness. Albuterol is classified as a short-acting beta-agonist, and its therapeutic use lies in its ability to provide quick relief during acute asthma attacks or to prevent exercise-induced bronchospasm.

Correct Answer: A

Rationale: Antihistamines target H1 receptors for allergy relief, not B1/B2 (choices B, C) or nonexistent C1 . A reflects their mechanism, making it correct.

Correct Answer: D

Rationale: Grade 1+ pitting edema in the feet is the information that should receive the most attention from the nurse when assessing a patient with a history of liver, prednisone, and azathioprine. Pitting edema in the feet may indicate fluid retention, which can be a sign of liver dysfunction or medication side effects. Therefore, it is crucial for the nurse to further investigate the edema, monitor the patient's fluid status closely, and possibly consult with the healthcare team for appropriate interventions. Swollen and pinkish gums may also be important to note, but pitting edema in the feet is more directly concerning in the context of the patient's history and medications.