The nurse is sitting at the desk watching the telemetry monitors and notes a patient's rhythm suddenly shows asystole. Which action should the nurse take first?

(A) Swallow the tablet whole with an 8 oz glass of water.
Sublingual nitroglycerin tablets should not be swallowed. They need to be placed under the tongue where they can dissolve and be absorbed quickly to provide rapid relief from angina.

(B) Store the medication in a pill box at the bedside.
Nitroglycerin sublingual tablets should be stored in their original container and kept tightly closed to protect them from light and moisture. Storing them in a pill box at the bedside could lead to degradation of the medication.

(C) Take the medication at the first indication of chest pain.
This is the correct instruction. Nitroglycerin sublingual tablets should be taken at the first sign of chest pain to provide prompt relief. The rapid onset of action helps to alleviate angina symptoms quickly.

(D) Remove the nitroglycerine patch before taking the sublingual tablet.
It is not necessary to remove the nitroglycerin patch before taking a sublingual tablet. The two forms of nitroglycerin can be used together, as the patch provides a continuous dose while the sublingual tablet offers rapid relief of acute symptoms.

(A) Treatment: While treatment is an important part of the client’s information, it is typically included in the “Recommendation” component of ISBARR, where the nurse would discuss the recommended treatment plan.

(B) List of medications: The list of medications a client is taking is crucial information, but it is usually included in the “Background” component of ISBARR, which provides context about the client’s medical history and current medications.

(C) Medical condition: This is the most appropriate answer. The “Situation” component of ISBARR is meant to provide a brief overview of the client’s current situation, which includes their current medical condition or reason for admission.

(D) Vital signs: Vital signs are typically included in the “Assessment” component of ISBARR, where the nurse would discuss the results of their assessment of the client, including vital signs.