The nurse in a clinic reviewing laboratory results for a patient suspected of having undiagnosed diabetes mellitus. Which of the following results would be diagnostic for diabetes

A. Auscultate the client’s apical pulse for a full minute:
While auscultating the apical pulse is important for certain cardiovascular conditions, it is not the primary action needed before administering sublingual nitroglycerin. The nurse's main priority is to assess the patient's blood pressure, as nitroglycerin can cause significant hypotension (a drop in blood pressure), and it is important to ensure the patient’s blood pressure is adequate before administration. If the blood pressure is too low, nitroglycerin should not be given.

B. Advise the client that vomiting is a primary side effect:
Vomiting is not a primary or common side effect of sublingual nitroglycerin. Nitroglycerin is more likely to cause headaches, dizziness, flushing, and hypotension. While it’s helpful to inform the patient about possible side effects, advising them that vomiting is a primary side effect could cause unnecessary concern or confusion.

C. Check the client’s blood pressure:
This is the correct action. Nitroglycerin works by dilating blood vessels, which can lower blood pressure. Before administering sublingual nitroglycerin, it is essential to check the client's blood pressure. If the client is hypotensive or has low blood pressure, nitroglycerin should be withheld, as it could further decrease blood pressure and worsen the patient’s condition. This is the priority nursing action to ensure the patient’s safety.

D. Obtain a STAT chest X-ray:
Obtaining a chest X-ray is not a priority action for a client with unstable angina before administering nitroglycerin. Chest X-rays are more useful for diagnosing conditions like pneumonia, pneumothorax, or other structural issues of the chest, but they are not immediately needed in the management of unstable angina. The most immediate concern is assessing the patient’s blood pressure before administering nitroglycerin.

A) Having 2 RNs ensure the blood product is properly labeled and matches the client’s identification:
Two registered nurses must independently verify that the blood product matches the patient's identification and that it is properly labeled. This is a critical safety measure to prevent errors, such as mismatched blood transfusions, which can lead to severe complications like hemolytic reactions. Proper verification before administration is a standard safety protocol in blood transfusion procedures.

B) Ensuring that the client signed a consent form for receiving blood transfusions beforehand:
Obtaining informed consent is a vital legal and ethical step before administering a blood transfusion. The nurse must ensure that the patient understands the potential risks and benefits of the procedure and has signed a consent form prior to transfusion. Without consent, the transfusion cannot legally be performed. This is a key part of patient rights and nursing responsibilities.

C) Preparing a primary and secondary IV tubing:
For blood transfusions, only blood administration tubing should be used, which typically includes a filter to prevent the infusion of any debris or clots. Using regular IV tubing (primary and secondary) for blood administration is not recommended, as it may not have the necessary filter and could potentially introduce contaminants. Blood should always be administered with tubing specifically designed for that purpose.

D) Obtaining a bag of 0.9% sodium chloride:
Normal saline is typically used as the solution to flush the IV line before and after the transfusion. It is compatible with blood products and helps to prevent clotting or reactions in the line. This is an essential step to ensure safe and effective blood administration.