Difficulty: Medium
Average Score: 94%
Simulated
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 min, the client states that his chest pain is now a severity of 2. Which of the following actions should the nurse take?
Correct answer
A
Rationale
Obtaining an ECG is the appropriate action to assess for any changes in the heart's electrical activity that may indicate worsening ischemia or other complications, such as a myocardial infarction. Even though the pain has decreased, it is important to evaluate the underlying cause of the chest pain, particularly with unstable angina.