A nurse is providing site care for a child who a gastrostomy enteral tube. Which of the following actions should the nurse take?

A) "I will stop what I am doing and lie down.": This is the correct response. When a client with stable angina experiences chest pain, they should stop any physical activity and rest in a comfortable position, preferably lying down. This helps reduce the heart’s workload and decrease the demand for oxygen, which can relieve the pain. Rest is important before taking any further action.

B) "I will take two 325 milligram aspirin tablets at the same time.": While aspirin can help reduce blood clot formation in some cases of chest pain, the recommended dosage is typically one 81-325 mg aspirin, not two 325 mg tablets. Taking two large doses may lead to an overdose or unwanted side effects. Additionally, this is not the immediate intervention for stable angina pain, which typically responds to rest and nitroglycerin.

C) "I will hold my breath and bear down.": This technique, known as the Valsalva maneuver, can increase intrathoracic pressure and slow the heart rate, but it is not recommended to relieve chest pain in stable angina. In fact, it could increase stress on the heart and worsen the symptoms. This maneuver is used in specific situations, such as slowing a rapid heart rate, not for chest pain relief.

D) "I will call the provider after taking one dose of nitroglycerin.": The client should first try nitroglycerin for chest pain as prescribed, and if the pain doesn’t resolve after one dose (or if it worsens), they should seek medical attention. However, in the case of stable angina, it's more appropriate to call the provider if the chest pain persists despite rest and nitroglycerin, not immediately after the first dose.

A) Autonomy: Autonomy refers to the right of individuals to make their own choices and decisions. While the nurse’s actions may promote the client’s independence in the future, the nurse’s promise to walk with the client does not directly address or uphold the client’s autonomy. The nurse is offering support rather than encouraging the client to make independent decisions about their participation in the exercise.

B) Fidelity: Fidelity involves being faithful and keeping promises or commitments. In this scenario, the nurse promises to walk with the client in the courtyard each day, and this promise demonstrates the ethical principle of fidelity. The nurse is demonstrating trustworthiness and loyalty by committing to help the client overcome their anxiety and follow through with the daily exercise.

C) Justice: Justice is the ethical principle that focuses on fairness and equal treatment for all individuals. While justice is important in providing equal care to all clients, it is not the primary principle in this scenario. The nurse’s actions focus on meeting the specific needs of the individual client, which is more aligned with fidelity.

D) Nonmaleficence: Nonmaleficence means “do no harm.” While the nurse’s goal is to prevent harm by helping the client address their anxiety, the primary ethical principle at play here is fidelity, as the nurse is keeping their promise to provide consistent support. Nonmaleficence would be more relevant if the nurse were directly addressing potential harm or risk associated with the client’s situation, but the promise to walk with the client focuses more on the nurse’s commitment.