The nurse is assessing a client 15 minutes after initiating nitroglycerin infusion for suspected acute coronary syndrome. Which clinical finding is the priority?

Question

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Nitroglycerin is a nitrate that causes vasodilation and relaxation of vascular smooth muscle. In clients with acute coronary syndrome, it is administered by IV infusion to decrease preload and prevent spasm of the coronary arteries, thereby increasing perfusion and oxygen supply to the cardiac muscle. Due to systemic vasodilation, this client is at risk for significant hypotension. The nurse should follow up immediately if the client reports dizziness or lightheadedness, which may indicate profound hypotension (Option B). If the client is found to be hypotensive, the nurse may need to decrease or discontinue the infusion. (Option A) Headache is a common side effect of nitroglycerin therapy and is often a sign that the medication is working properly. It is not a priority, although acetaminophen may be given for pain relief. (Options C and D) Systemic vasodilation and decreased cardiac preload may cause the client to feel flushed and nervous during infusion. However, reports of dizziness and lightheadedness should take priority. Educational objective: Nitroglycerin is a vasodilator that may be administered by IV infusion in the management of acute coronary syndrome. Clients receiving nitroglycerin are at risk for profound hypotension resulting from systemic vasodilation. The nurse should immediately assess a client with signs of hypotension (eg, dizziness, lightheadedness) because the nitroglycerin infusion may need to be decreased or stopped.

The Nurse Is Assessing a Client 15 Minutes After Initiating