1. A patient with a history of hypertension and angina is admitted to the

hospital with chest pain. The nurse administers nitroglycerin sublingually

and monitors the patient's vital signs. Which of the following findings

indicates that the nitroglycerin is effective? (Select all that apply.)

A) The patient's blood pressure decreases to 120/80 mmHg.

B) The patient's heart rate increases to 100 beats per minute.

C) The patient's chest pain subsides within 5 minutes.

D) The patient's skin becomes warm and flushed.

E) The patient's respiratory rate decreases to 12 breaths per minute.

Answer: A, C, D

Rationale: Nitroglycerin is a vasodilator that reduces the preload and

afterload on the heart, lowering the blood pressure and decreasing the

oxygen demand of the myocardium. It also dilates the coronary arteries,

increasing the blood flow to the ischemic areas of the heart. These effects

can relieve angina and lower the risk of myocardial infarction.

Nitroglycerin can cause reflex tachycardia, which is an undesirable side

effect that increases the cardiac workload. It can also cause headache,

dizziness, and hypotension. Nitroglycerin does not affect the respiratory

rate.

2. A nurse is caring for a patient who has just undergone coronary artery

bypass graft (CABG) surgery. The nurse notices that the patient's chest

tube drainage has increased from 50 mL/hour to 150 mL/hour in the last

hour. What is the nurse's priority action?

A) Notify the surgeon immediately.

B) Clamp the chest tube and observe for changes.

C) Administer a bolus of normal saline intravenously.

D) Document the finding and continue to monitor.

Answer: A

Rationale: An increase in chest tube drainage after CABG surgery can

indicate bleeding or cardiac tamponade, which are life-threatening

complications that require immediate intervention. The nurse should

notify the surgeon as soon as possible and prepare for emergency

measures such as chest tube reinsertion, pericardiocentesis, or surgery.

Clamping the chest tube can worsen the situation by increasing the

intrathoracic pressure and impairing cardiac output. Administering a bolus

of normal saline can increase the fluid volume and exacerbate the bleeding