Question

A nurse on telemetry unit is caring for a client who has unstable angina and is reporting chest pain with a severity of 6 on a 0 to 10 scale. The nurse administers 1 sublingual nitroglycerin tablet. After 5 min, the client states that his chest pain is now a severity of 2. Which of the following actions should the nurse take?

a. Administer another nitroglycerin tablet.

b. Initiate a peripheral IV.

c. Call the Rapid Response Team.

d. Obtain an ECG

Answer 1

The nurse should consider administering another nitroglycerin tablet and obtaining an ECG to monitor for ongoing ischemia, while also preparing for possible additional interventions.

Step-by-step explanation:

The nurse should take into consideration that the patient with unstable angina has reported a significant decrease in chest pain severity, from a 6 to a 2 on a 0 to 10 scale, after administering sublingual nitroglycerin. Given the improvement but the continuation of some pain, it is appropriate to administer another nitroglycerin tablet if the protocol allows for it and to monitor the patient closely. It is also essential to obtain an ECG to assess for any changes that might indicate an ongoing ischemic process or the development of an acute myocardial infarction (MI). Initiation of a peripheral IV may be warranted for potential administration of further medications, while calling the Rapid Response Team would depend on any deterioration of the patient's condition or failure to improve with additional nitroglycerin administration.