How will the nurse administer a nitroglycerin sublingual tablet to the patient?

Choice A rationale:

STAT orders are urgent and require immediate action. They are typically used for life-threatening situations or when a rapid response is needed to prevent serious harm. In this case, an EKG is important for patients admitted to the cardiac unit, but it is not necessarily an urgent procedure that requires immediate action in all cases.

STAT orders are often given verbally or over the phone, and they are typically written in all capital letters with the word "STAT" prominently displayed.

Examples of STAT orders include medications for cardiac arrest, intubation for respiratory distress, or emergency surgery for a ruptured appendix.

Choice B rationale:

PRN orders are "as needed" orders, meaning they are only carried out when a specific condition or symptom arises. They are not routinely implemented for all patients in a particular unit or setting.

PRN orders allow for flexibility in treatment plans and can help to manage pain, nausea, anxiety, or other symptoms that may fluctuate over time.

Examples of PRN orders include pain medication, anti-nausea medication, or sedatives.

Choice C rationale:

One-time orders are administered only once and are not repeated. They are often used for procedures, diagnostic tests, or medications that are not required on an ongoing basis.

In this case, an EKG is typically a one-time order for patients outside of the cardiac unit, but it becomes a standing order for patients admitted to the cardiac unit due to the increased importance of cardiac monitoring in this setting.

Examples of one-time orders include a chest X-ray, a blood draw, or a dose of antibiotics.

Choice D rationale:

Standing orders are routine orders that are implemented for all patients in a particular unit or setting, unless otherwise specified. They are designed to provide consistent and standardized care, and they often reflect best practices or guidelines for a specific patient population.

Standing orders can help to streamline care processes, reduce the need for individual orders, and ensure that patients receive necessary treatments or interventions without delay.

In this case, the standing order for an EKG upon admission to the cardiac unit ensures that all patients receive this important cardiac assessment, even if the ordering provider does not specifically write an order for it.

Other examples of standing orders in a cardiac unit might include daily weights, regular vital sign checks, or administration of cardiac medications.

Choice B rationale:

Heart rate: During a stress response, the sympathetic nervous system is activated, leading to a release of hormones such as adrenaline and cortisol. These hormones increase heart rate, preparing the body for a "fight or flight" response. A heart rate of 132 beats per minute is significantly elevated compared to a normal resting heart rate of 60-100 beats per minute, suggesting a stress response.

Choice C rationale:

Pupil dilation: Pupil dilation is another physiological change associated with the activation of the sympathetic nervous system during stress. The dilation allows more light to enter the eyes, enhancing visual acuity and awareness of surroundings, which can be helpful in responding to potential threats.

Choice E rationale:

Difficulty sleeping: Stress can negatively impact sleep in several ways. It can cause racing thoughts, anxiety, and physical tension, making it difficult to fall asleep and stay asleep. Sleep disturbances are a common symptom of stress and can further exacerbate its effects.

Rationale for incorrect choices:

Choice A: Blood glucose level can be affected by stress, but a low blood glucose level of 36 mg/dL is more likely to be due to other causes such as hypoglycemia or insulin therapy. It's not a direct indicator of a stress response.

Choice D: Blood pressure can increase during stress, but a blood pressure of 104/56 mmHg is within the normal range and does not necessarily indicate a stress response.