Which information should the registered nurse include when teaching the client about the prescribed transdermal nitroglycerin patch? Select all that apply.

Choice A rationale

Assessing the client's level of pain is important in many situations, but in an unresponsive client, airway and breathing take immediate priority. An unresponsive client cannot communicate pain, and addressing potentially life-threatening issues like airway obstruction or respiratory arrest is paramount.

Choice B rationale

Checking the client's airway and breathing is the priority nursing action for an unresponsive client. Unresponsiveness can indicate a critical condition that may compromise the client's ability to maintain a patent airway or breathe effectively. Ensuring a clear airway and adequate ventilation are essential for preventing hypoxia and death. This aligns with the ABC (Airway, Breathing, Circulation) approach to emergency care.

Choice C rationale

Documenting the client's Glasgow Coma Scale (GCS) score is important for assessing the level of consciousness and neurological function. However, in an unresponsive client, ensuring airway and breathing precedes a detailed neurological assessment. The GCS can be assessed after immediate life-threatening issues are addressed.

Choice D rationale

Obtaining a detailed neurological history from family can provide valuable information, but it is not the priority in the immediate management of an unresponsive client. Addressing the client's immediate physiological needs, such as airway and breathing, takes precedence over gathering historical information.

Choice A rationale

Acetaminophen is an appropriate analgesic for managing headaches, a common side effect of nitroglycerin due to vasodilation. It does not interfere with the therapeutic effects of nitroglycerin and provides symptomatic relief. Other non-steroidal anti-inflammatory drugs (NSAIDs) might be contraindicated in some cardiac patients, making acetaminophen a safer initial choice for headache management in this context.

Choice B rationale

Touching the medication portion of the transdermal patch can lead to unintended absorption of the nitroglycerin by the person applying it. This could result in side effects such as headache or hypotension in the caregiver. Maintaining the integrity of the dosage and preventing accidental exposure are crucial for safe medication administration.

Choice C rationale

Applying the nitroglycerin patch to a different site each day helps prevent skin irritation and sensitization at the application site. Consistent use on the same area can lead to local reactions, reduced absorption, and potential skin breakdown. Rotating sites ensures optimal drug absorption and minimizes dermatological complications.

Choice D rationale

Applying the nitroglycerin patch to hairy areas can impede proper adhesion to the skin, potentially affecting the absorption and efficacy of the medication. Hair can create a barrier, preventing consistent contact between the patch and the skin's surface, thus reducing the intended therapeutic effect.