A client is to receive 250,000 units of benzathine penicillin.
G. The medication is available in a vial containing 300,000 units per milliliter. How many milliliters should a nurse administer?

Determining whether chest pain has been relieved. This is because nitroglycerin is a medication that is used to treat chest pain caused by cardiac origin or acute pulmonary edema. The main action of nitroglycerin is to relax and dilate the blood vessels, which reduces the workload of the heart and improves blood flow to the heart muscle.

Therefore, the most important nursing action after administering nitroglycerin sublingually is to assess if the chest pain has subsided or not.

Choice A is wrong because monitoring the client’s respiratory rate and effort is not the most important action after giving nitroglycerin. Although nitroglycerin can cause hypotension and bradycardia, which may affect the respiratory status, these are side effects that can be managed and are not life-threatening as chest pain.

Choice B is wrong because warning the client to lie still to prevent a headache is not a priority after giving nitroglycerin. Nitroglycerin can cause headache as a side effect, but this can be treated with analgesics and does not require the client to lie still. Moreover, lying still may increase the risk of venous thromboembolism in a client with peripheral vascular disease.

Choice D is wrong because verifying that the sublingual tablet produced a tingling sensation is not essential after giving nitroglycerin.

Although some sublingual tablets may produce a tingling sensation, this is not a reliable indicator of the drug’s effectiveness

Notify the health care provider. The nurse should take this action first because the provider can prescribe appropriate interventions to prevent or minimize harm to the client.

The nurse should also inform the unit supervisor, document the error in the client’s medical record, and record the error on the appropriate quality improvement report, but these are not the priority actions.

Choice A is wrong because informing the unit supervisor is not the most urgent action. The supervisor can provide support and guidance to the nurse, but cannot prescribe interventions for the client.

Choice C is wrong because documenting the error in the client’s medical record is not the most urgent action.

The nurse should document the error after notifying the provider and assessing the client. Documentation should include the medication name, dose, route, time, client’s response, and actions taken.

Choice D is wrong because recording the error on the appropriate quality improvement report is not the most urgent action.

The nurse should record the error after notifying the provider and assessing the client. The report should include a factual description of what happened and what was done.