Question

a nurse is caring for a client who is taking nitroglycerin for angina and reports feeling faint when standing up. which of the following actions should the nurse take?

inform the client that feeling faint is caused by rapid constriction of the blood vessels in the legs.
assist the client into bed, elevate the lower extremities, and check their blood pressure.
request a prescription for dobutamine from the clients provider.
check the clients blood pressure while theyre still standing.

Explanation:

Analyze the clinical scenario

The client is taking nitroglycerin, a potent vasodilator used for angina. Nitroglycerin causes systemic vasodilation, which decreases venous return and cardiac output, frequently leading to orthostatic (postural) hypotension. This explains why the client feels faint upon standing up.

Evaluate the first option

Using the Nursing Assessment knowledge point
The first option states that feeling faint is caused by rapid constriction of blood vessels in the legs. This is physiologically incorrect; nitroglycerin causes vasodilation (dilation), not constriction, which leads to blood pooling in the lower extremities and a subsequent drop in blood pressure.

Evaluate the second option

Using the Nursing Assessment knowledge point
The second option suggests assisting the client into bed, elevating the lower extremities, and checking their blood pressure. This is the correct nursing action. Placing the client in a supine position with legs elevated promotes venous return to the heart, increases cardiac output, and restores cerebral perfusion to relieve the faintness. Assessing the blood pressure is the appropriate immediate assessment to evaluate the severity of the hypotension.

Evaluate the third and fourth options

Using the Nursing Assessment knowledge point

• Dobutamine is an inotropic agent used for severe heart failure or cardiogenic shock, not for managing transient orthostatic hypotension from nitroglycerin.
• Checking the blood pressure while the client is still standing is unsafe because the client is currently feeling faint and is at a high risk for syncope (fainting) and falling.

Determine the correct action

The safest and most appropriate immediate nursing intervention is to assist the client to a safe supine position, elevate their legs to improve cerebral blood flow, and measure their blood pressure.

Answer:

• Inform the client that feeling faint is caused by rapid constriction of the blood vessels in the legs.
• Assist the client into bed, elevate the lower extremities, and check their blood pressure. (Correct answer)
• Request a prescription for dobutamine from the client's provider.
• Check the client's blood pressure while they're still standing.