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    Hesi med surg proctored exam (respgitcvs) MCHPS University

    After administering nitroglycerin spray to a client experiencing angina, which action should the nurse implement next?

    Explanation & Rationale

    Rationale: A. Elevate the client’s feet: Raising the feet is an intervention used to improve venous return in cases of hypotension or shock. While nitroglycerin can cause a drop in blood pressure, the priority after administration is to reduce cardiac workload through rest. B. Advise the client to rest: Rest is essential following nitroglycerin administration because it decreases myocardial oxygen demand and enhances the medication’s effectiveness in relieving angina. Activity could worsen chest pain by increasing cardiac workload, so ensuring the client remains still is the most important next action. C. Observe for facial flushing: Flushing is a common side effect of nitroglycerin due to vasodilation. While the nurse should monitor for this, it is not a priority action compared to promoting rest and limiting cardiac strain after an angina episode. D. Compress the client’s nares: This intervention is related to managing epistaxis and is not relevant to nitroglycerin spray administration. It does not address the client’s angina or the expected effects of the medication.

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