A client with a long-standing diagnosis of angina has been prescribed nitroglycerin and diltiazem. In addition to monitoring the client's heart rate, the nurse should prioritize what assessment?
Blood pressure
Level of consciousness
Daily weights
Respiratory status
The Correct Answer is A
A. Blood pressure is correct because both nitroglycerin and diltiazem can cause vasodilation, leading to hypotension; thus, monitoring blood pressure is crucial for patient safety.
B. Level of consciousness is incorrect; while important, it is not the primary concern in this context.
C. Daily weights are incorrect; they are more relevant for assessing fluid status over time, not immediate drug effects.
D. Respiratory status is incorrect; while monitoring is important, blood pressure takes precedence due to the risk of hypotension associated with these medications.
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Correct Answer is B
Explanation
A. Bruising and bleeding gums are not indicative of an allergic reaction, which would typically present with different symptoms such as rash, itching, or swelling. Administering antihistamines would not address the underlying issue.
B. The development of bruising and bleeding gums in a patient on heparin therapy suggests a bleeding complication, which is a known risk of anticoagulation therapy. The nurse should notify the healthcare provider to assess the situation and possibly adjust treatment or perform further evaluations.
C. While hypersensitivity reactions can occur with medications, the symptoms presented here are more aligned with bleeding complications than with hypersensitivity. Discontinuing heparin without consulting the provider could put the patient at risk for thromboembolic events.
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Correct Answer is B
Explanation
A. This statement is accurate as antiviral drugs primarily reduce the severity and duration of viral infections but do not prevent transmission to others.
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C. This statement is correct; following prescribed application guidelines for topical antivirals is essential to avoid skin irritation or decreased efficacy.
D. This statement is also correct, as using gloves or a finger cot is recommended to prevent contamination and protect the healthcare worker from exposure while applying topical antivirals.