A nurse is preparing to administer vancomycin 500 mg PO daily divided into four equal doses. The amount available is vancomycin 125 mg capsules. How many capsules should the nurse administerwitheachdose?

A. "Only take one nitroglycerin tablet for each episode of angina."

This instruction is correct. Sublingual nitroglycerin is typically administered as needed for the relief of angina symptoms, with one tablet being the initial dose. If the chest pain persists after 5 minutes, the client may take a second tablet, and if needed, a third tablet after another 5 minutes. However, if the pain is not relieved after three tablets, they should seek immediate medical attention.

B. "Place the nitroglycerin tablet between cheek and gum."

This instruction is incorrect. Sublingual nitroglycerin tablets should be placed under the tongue, allowing them to dissolve and be absorbed directly into the bloodstream. Placing the tablet between the cheek and gum is not the recommended administration route for sublingual nitroglycerin.

C. "Call 911 if you develop a headache following nitroglycerin use."

This instruction is partially correct. Headache is a common side effect of nitroglycerin due to its vasodilatory effects. Clients should be informed about this potential side effect, but not every headache following nitroglycerin use requires immediate medical attention. However, if the headache is severe, persistent, or accompanied by other concerning symptoms, the client should seek medical evaluation.

D. "See if rest relieves the chest pain before using the nitroglycerin."

This instruction is incorrect. Sublingual nitroglycerin is a rapid-acting medication used to relieve angina symptoms quickly. Clients should not delay taking nitroglycerin and wait for rest to relieve chest pain, as this can lead to worsening symptoms and complications.

A. Initiate a peripheral IV:

Initiating a peripheral intravenous (IV) line may be necessary for clients with unstable angina to facilitate the administration of medications and fluids, especially if there is a need for further interventions or if the client's condition deteriorates. However, in this case, the client's chest pain has improved after receiving nitroglycerin, and there is no immediate indication for IV access based on the information provided.

B. Administer another nitroglycerin tablet:

Nitroglycerin is a vasodilator commonly used to relieve chest pain (angina) by dilating blood vessels and improving blood flow to the heart. The initial response of the client's chest pain severity decreasing from 6 to 2 after one sublingual nitroglycerin tablet indicates a positive response to the medication. However, it's important to assess the client's response further before administering additional doses of nitroglycerin, especially considering the potential for hypotension or other adverse effects.

C. Call the Rapid Response Team:

The Rapid Response Team (RRT) is typically called in situations where there is a concern for a critical event or deterioration of a client's condition that requires immediate intervention. In this scenario, the client's chest pain has improved after nitroglycerin administration, and there are no indications of an acute critical event at this time. Therefore, calling the RRT is not warranted based on the client's current status.

D. Obtain an ECG:

An ECG can be helpful to assess for potential ischemia or other cardiac abnormalities. However, it's not the most urgent action when the client is responding positively to nitroglycerin. It can be done while monitoring the client's response to the second dose.