How many nitro tabs before pt should call 911?

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    I am studying for my final in Med Surg II and am totally confused about nitro. I am doing practice NCLEX questions from an NCLEX book. The question was "Which comment by the client would indicate to the nurse that the client understands how to take his sublingual nitroglycerine?" The first answer was "I will call 911 if the pain does not go away within 5 minutes after taking the medication." Wrong, I thought because I remembered in Pharmacology how my professor emphasized patients can take three tabs before calling 911. Anyways, my answer was wrong and the first answer was correct!

    The rationale the book gave was "The EMS should be activated if the client's chest pain is not relieved within 5 minutes of taking the nitroglycerine." I thought that was odd, so I looked in my Med Surg textbook. It also said to call 911 after 5 minutes/one dose. So then I dug out my Pharmacology book. This is exactly what it says under patient education for nitro:

    "Explain that if angina is not relieved, up to two more tablets may be taken; one 5 minutes after the first tablet and the other 5 minutes after the second tablet. Instruct the patient to go to the nearest emergency department if angina is not relieved after the above measures are taken."

    Am I missing something here? These answers seem to be extremely different. My NCLEX book and Med Surg book are Mosby Elsevier and my Pharm book is Lippincott. Why would there be a discrepancy?
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  3. 12 Comments so far...

  4. 2
    It probably has to do with differing recommendations. Because SL Nitro works so quickly, if chest pain isn't relieved with that first dose, call 911 because chances are good that the problem is an actual MI instead of "just" angina. Also, the longer you wait, the more muscle gets injured/dies, so they want to minimize the amount of time the patient waits before reaching the cath lab or gets thrombolytics.

    On the other hand, with people that have angina, they may be told to wait for the 3rd dose as it may take one or two for the NTG to take sufficient effect.

    All told, it may just simply have to do with the current thinking in place at the time the books were published. Personally, I would think that having the patient call after the 1st NTG was given would be the better of the two answers because it minimizes time to definitive treatment and there's always the possibility that the NTG tablet could be out-dated and less effective.
    summer-dreamer and sandyfeet like this.
  5. 1
    We were first taught 3 doses then 911 (doses 5 min apart) but in second year we were told they changed the standards and after first dose if no relief call 911 and take second dose.
    sandyfeet likes this.
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    Thanks for the replies! I wanted to make sure I wasn't reading something wrong during my final studying session before my finals.
    I know that going into nursing, I am going to see a lot of changes in medicine and care, but it kind of blows my mind that I've seen one in nursing school! I took Pharm only 2 years ago!
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    Hello, I work in a hospital in a outpatient cardiac rehab program. Our protocol is give one nitro. SL and wait 5 min., along with some other protocols to follow, re-evaluate and if pt. still having CP, give another nitro SL. No more than 3 within 15 minutes. I instructed them for at home to do the same thing. However, if they are still having CP after the 3rd nitro. I tell them to call 911. And stress the importance of not driving themselves to the hospital. Maybe this is something that I should do some research on. We all know that EMS can provide that immediate treatment if needed, and time is of the essence. Thanks for making me think. Have a great day!
    sandyfeet likes this.
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    Thanks for the reply! It's good to hear about what is going on in the real world too.
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    What were the other options? If the other 3 answers were obviously wrong, then choice #1 would be the best answer.
  10. 0
    Quote from GoodtimeCNA
    What were the other options? If the other 3 answers were obviously wrong, then choice #1 would be the best answer.
    If only they were obviously wrong!

    "I will put the nitroglycerine between my cheek and gum whenever I begin to have any chest pain." (Wrong because it says in the stem that the drug is sublingual)

    "I will take the nitroglycerine when I get up in the morning and whenever I experience chest pain during the day." (Wrong...but some sources say to take nitro as a prophylactic for activities that could cause chest pain...could read too far into this one...)

    "I know that nitroglycerine is important to help prevent any further damage to the arteries in my heart." (Um...well it dilates the arteries...too much constriction could cause damage...right?)

    It's a credit to my Pharm professor that I remembered her example 2 years after the fact! She made us calculate the exact time with this crazy question, something like "Your patient takes the first tab at 12:00, when do they call". Now I must un-remember.
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    This is what is so tricky about nursing questions. The question was "Which comment by the client would indicate to the nurse that the client understands how to take his sublingual nitroglycerine?" The option about dilating arteries is how it works, but not how to take it. That's what I got out of it.

    Thanks for bringing this point up, though, because my professors also taught us take 3, 5 mins apart, then call 911 if pain is not relieved after the last one. It might come up on a test for me one day!


    Quote from sandyfeet
    If only they were obviously wrong!

    "I will put the nitroglycerine between my cheek and gum whenever I begin to have any chest pain." (Wrong because it says in the stem that the drug is sublingual)

    "I will take the nitroglycerine when I get up in the morning and whenever I experience chest pain during the day." (Wrong...but some sources say to take nitro as a prophylactic for activities that could cause chest pain...could read too far into this one...)

    "I know that nitroglycerine is important to help prevent any further damage to the arteries in my heart." (Um...well it dilates the arteries...too much constriction could cause damage...right?)

    It's a credit to my Pharm professor that I remembered her example 2 years after the fact! She made us calculate the exact time with this crazy question, something like "Your patient takes the first tab at 12:00, when do they call". Now I must un-remember.
  12. 0
    This is what we were told in Pharm, Take 1st Nitro wait 5 mins, if pain persist call 911 and take 2nd dose while waiting for EMS. Professor said its best to have them in route, get there, and not need them than to not call and be unable to get to the phone after dose # 2 or #3 doesnt work.


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