A nurse is performing tracheostomy care for a client who has a chronic tracheostomy. Which of the following actions should the nurse take?

Choice A reason: Taking four nitroglycerin sublingual tablets if having chest pain is an incorrect statement that indicates a lack of understanding of the teaching. Nitroglycerin is a medication that dilates the coronary arteries and relieves angina by improving blood flow to the heart. The client should take one nitroglycerin tablet every 5 minutes for up to three doses if having chest pain. If the pain persists after three doses, the client should call emergency response.

Choice B reason: Notifying emergency response if having sudden jaw pain is a correct statement that indicates an understanding of the teaching. Jaw pain is one of the possible signs of a heart attack, which is a life-threatening condition that occurs when the blood supply to the heart is blocked. Other signs of a heart attack include chest pain, arm pain, shortness of breath, nausea, sweating, or dizziness. The client should seek immediate medical attention if experiencing any of these symptoms.

Choice C reason: Waiting 30 minutes before taking action if having heartburn is an incorrect statement that indicates a lack of understanding of the teaching. Heartburn is a burning sensation in the chest or throat that can be caused by acid reflux, gastritis, or other gastrointestinal disorders. However, heartburn can also mimic or mask angina or a heart attack, especially in women, elderly, or diabetic clients. The client should not ignore or delay seeking help if having chest discomfort that may be related to cardiac problems.

Choice D reason: Having hot, dry, and flushed skin if having a heart attack is an incorrect statement that indicates a lack of understanding of the teaching. Hot, dry, and flushed skin is not a typical sign of a heart attack, but it may indicate fever, dehydration, or allergic reaction. The client should monitor his temperature and hydration status and report any abnormal findings to the provider.

Choice A reason: This is not an essential safety measure because the nurse should wear a mask only when they are within 3 feet of the client who has pneumonia and is on droplet precautions, according to the Centers for Disease Control and Prevention (CDC) guidelines. The nurse should wear a mask when entering the client's room, but they can remove it when leaving the room or transporting the client.

Choice B reason: This is not an essential safety measure because the nurse should wear a gown only when they anticipate contact with the client's blood, body fluids, secretions, or excretions, according to the CDC guidelines. The nurse should wear a gown when entering the client's room, but they can remove it when leaving the room or transporting the client.

Choice C reason: This is an essential safety measure because the client should wear a mask during transport to prevent the spread of respiratory droplets that may contain infectious agents, such as bacteria or viruses, that cause pneumonia, according to the CDC guidelines. The nurse should instruct the client to wear a mask before leaving the room and ensure that it covers their nose and mouth.

Choice D reason: This is not an essential safety measure because the client should wear a gown only if they have drainage or soiling of their clothing that may contaminate the environment, according to the CDC guidelines. The nurse should assess the client's condition and provide a clean gown if needed before leaving the room.