A nurse on a telemetry unit is caring for a client who has unstable angina and is reporting chest pain with a severity of 6 on a 0 to 10 scale.The nurse administers 1 sublingual nitroglycerin tablet.
After 5 minutes, the client states that his chest pain is now a severity of 2. Which of the following actions should the nurse take?

Choice C rationale

Administering another nitroglycerin tablet is appropriate if the client's chest pain has not been fully relieved after the initial dose. Nitroglycerin helps to dilate blood vessels, improving blood flow to the heart and relieving angina. A second dose can be given if the pain persists, following the protocol for managing chest pain.

Choice A rationale

Obtaining an ECG is important for diagnosing and monitoring cardiac conditions; however, in this immediate context, further pain relief takes precedence. After ensuring pain relief, an ECG can be performed to assess the client's cardiac status.

Choice B rationale

Calling the Rapid Response Team is unnecessary if the client’s chest pain severity has already decreased. The priority should be to continue managing the chest pain with additional nitroglycerin if needed and monitoring the client's response.

Choice D rationale

Initiating a peripheral IV might be required for administering medications or fluids, but it is not the immediate action needed in this scenario. The priority is to provide additional pain relief with nitroglycerin.