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CCRN Nursing Exam Prep - Adult Critical Care

Category - Adult Critical Care Registered Nurse Test Prep

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A patient comes to the Cardiovascular Care Unit with a blood pressure of 94/68, a heart rate of 124 and chest pain rated as 8/10. The patient has already taken one 0.04 mg tablet of Nitroglycerin five minutes ago. What should the nurse do next?
  1. Take the patient’s blood pressure and put them on the monitor.
  2. Administer a dose of Morphine 2 mg IV and re-assess pain.
  3. Obtain a stat EKG.
  4. Administer another dose of 0.04 mg tablet of Nitroglycerin.
Explanation
Answer: D - The next thing the nurse should do with this patient is to give an additional dose of 0.04 mg tablet of Nitroglycerin. Patients can take up to three sublingual Nitroglycerin tablets within 15 minutes. It may take 5 to 10 minutes to relieve chest pain. After administering the Nitroglycerin, the nurse can take vital signs and obtain an EKG. However, it is primarily important to relieve the chest pain.
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