Your client is complaining of "sudden, crushing chest pressure", and is having difficulty breathing.
Her physician has ordered a STAT dose of nitroglycerin. When should you administer the medication?

Choice A rationale

Instilling water to rinse the tube is an important step after medication administration or prior to administering incompatible medications, but it is not the initial and most crucial step before delivering any drug. Placement verification is paramount.

Choice B rationale

Scientifically, confirming tube placement is the absolute first and most critical step before administering any substance, including medication, through an enteral tube. Misplaced tubes can lead to aspiration pneumonia or inefficient drug absorption, posing significant patient safety risks.

Choice C rationale

Laying the client flat may increase the risk of aspiration, especially if the tube is misplaced or if the client has impaired gag reflex. Proper positioning, typically semi-Fowler's, is crucial for safe enteral feeding and medication administration.

Choice D rationale

Assessing bowel sounds is important for evaluating gastrointestinal motility and absorption capacity before initiating or continuing enteral feedings, but it is not the primary immediate safety check required before administering a single dose of medication.

Choice A rationale

Inspection is the systematic observation of the patient using the senses of sight, smell, and hearing. It is always the first technique used in a physical assessment because it provides a foundational understanding of the patient's general appearance, symmetry, posture, skin condition, and any visible abnormalities before physical contact is made.

Choice B rationale

Auscultation involves listening to sounds produced by the body, such as heart sounds, lung sounds, and bowel sounds, using a stethoscope. While crucial for assessing various body systems, it typically follows inspection and palpation to avoid altering natural body sounds.

Choice C rationale

Percussion involves tapping on body surfaces to elicit sounds that indicate the density of underlying tissues and organs. This technique helps in assessing organ size, shape, and consistency, but it is performed after inspection and palpation, as it involves direct contact and manipulation.

Choice D rationale

Palpation involves using the sense of touch to assess characteristics such as texture, temperature, moisture, organ size and location, and tenderness. While a vital component of the physical assessment, it follows inspection to avoid introducing discomfort or altering initial observations.