Which medication, if taken within the last 24-48 hours, would prevent a nurse from administering nitroglycerin?

Choice A rationale:

Hypoglycemia is a critical consideration: The patient's symptoms of lethargy, diaphoresis, and combativeness, along with recent insulin administration, raise a strong suspicion of hypoglycemia (low blood sugar). Hypoglycemia can quickly progress to coma and seizures if not promptly treated, making it a high priority to assess and address.

Bedside glucose testing is rapid and reliable: A bedside finger stick blood glucose test is a quick, non-invasive, and accurate way to determine the patient's blood sugar level. It provides immediate results, allowing for prompt intervention if hypoglycemia is confirmed.

Other assessments and interventions can follow: Once hypoglycemia is ruled out or confirmed, the nurse can proceed with other assessments and interventions as needed.

Choice B rationale:

Insulin administration without blood sugar confirmation is dangerous: Administering insulin without first checking the patient's blood sugar could worsen hypoglycemia if it is already present. This could lead to severe complications, including neurological damage or even death.

Insulin timing is not a priority: While the next dose of insulin may be due, its administration is not the most urgent priority in this situation. Addressing the patient's immediate symptoms and potential hypoglycemia takes precedence.

Choice C rationale:

Naloxone is not indicated for hypoglycemia: Naloxone is an opioid antagonist used to reverse opioid overdose. It has no effect on hypoglycemia and would not be appropriate in this case.

Choice D rationale:

Oxygen therapy may not address the underlying issue: While oxygen therapy can be beneficial for patients with respiratory distress, it does not address the potential hypoglycemia in this case. If the patient's lethargy and combativeness are due to low blood sugar, oxygen therapy alone would not be sufficient treatment.

Oxygen saturation is already within normal limits: The patient's oxygen saturation (SPO2) is 97%, indicating that their oxygenation is currently adequate. Oxygen therapy would not be indicated unless there were signs of hypoxia.

Choice A rationale:

Placing the tablet under the patient's nose is not an effective method of administering aspirin. Aspirin is not absorbed through the nasal mucosa.

This action would not provide any therapeutic benefit to the patient with a suspected myocardial infarction. It could potentially lead to aspiration of the tablet if the patient sneezes or coughs.

Choice B rationale:

Enteric-coated aspirin tablets are designed to dissolve in the intestines, not in the stomach. This delays the absorption of aspirin and its antiplatelet effects.

In a patient with a suspected myocardial infarction, it is crucial to achieve rapid absorption of aspirin to inhibit platelet aggregation and prevent further clot formation.

Therefore, enteric-coated aspirin is not appropriate in this situation.

Choice C rationale:

Chewing the aspirin tablet would indeed speed up its absorption. However, it also increases the risk of gastric irritation and bleeding.

Aspirin can be irritating to the stomach lining, and chewing it can exacerbate this effect.

This is particularly concerning in a patient with a suspected myocardial infarction, who may already be at risk for gastrointestinal bleeding due to decreased blood flow to the stomach.

Choice D rationale:

Giving the aspirin tablet with a small sip of water is the most appropriate action for the nurse to take in this situation. This allows for timely absorption of the aspirin while minimizing the risk of gastric irritation.

The water helps to dissolve the tablet and transport it to the stomach, where it can be absorbed into the bloodstream. It also helps to lubricate the esophagus and reduce the risk of the tablet becoming lodged in the throat.