A nurse is caring for a patient with stable angina who has been prescribed nitroglycerin sublingual tablets. What is the most appropriate nursing intervention when administering this medication?
1Administer the medication with a small amount of water to ensure proper absorption
2Have the patient chew the tablet thoroughly before swallowing to increase effectiveness
3Instruct the patient to place the tablet under the tongue and avoid swallowing until it dissolves completely✓ 정답
4Crush the tablet and mix it with applesauce for easier administration
해설
Nitroglycerin sublingual tablets must be placed under the tongue for rapid absorption through mucous membranes. Other methods (water, chewing, crushing) reduce effectiveness by altering absorption.
Core Nursing ExplanationKey Concept Analysis: This question tests the correct administration technique for sublingual nitroglycerin, a cornerstone medication for treating acute angina pectoris. The key principle is rapid absorption via the sublingual mucosa to achieve a quick therapeutic effect, bypassing the first-pass metabolism of the liver that occurs with oral (swallowed) medications.
Answer Rationale: Key Point! The correct method is to instruct the patient to place the tablet under the tongue and let it dissolve completely without swallowing. This allows the medication to be absorbed directly into the rich vascular network of the sublingual mucosa, entering the systemic circulation quickly to relieve coronary artery vasospasm and reduce cardiac workload, thereby alleviating chest pain within 1-3 minutes.
Distractor Analysis:
Option ① is incorrect because administering with water dilutes the medication and promotes swallowing, which significantly delays onset of action and reduces bioavailability due to hepatic first-pass effect.
Option ② is incorrect because chewing the tablet destroys the intended sublingual delivery system, causing most of the drug to be swallowed and digested, again delaying and diminishing its effect.
Option ④ is incorrect because crushing the tablet and mixing it with food converts it into an oral administration, completely negating the purpose of the sublingual route. It also makes dosing inaccurate.
Related Concepts: This administration principle applies to all true sublingual medications. Patient education is critical: they should sit or lie down before administration (to prevent hypotension-induced falls), expect a tingling or burning sensation under the tongue, and call emergency services if pain is not relieved after 3 doses taken 5 minutes apart.
Concept Summary
Concept
Key Points
Sublingual Administration
Place under tongue. Do not chew, swallow, or drink water. Let it dissolve. Rapid absorption bypasses liver.
Nitroglycerin Mechanism
Venous and arterial vasodilator. Reduces preload and afterload, decreasing myocardial oxygen demand. Relieves coronary vasospasm.
Patient Education for Angina
Take at first sign of pain. Sit/rest. Dose: 1 tab q5min x3 max. Seek emergency help if no relief after 3rd dose. Store in original dark glass bottle.
Side-by-Side Comparison!
Route
Nitroglycerin Form
Onset of Action
Key Nursing Point
Sublingual
Tablet
1-3 minutes
Do not swallow! Let dissolve under tongue.
Translingual
Spray
1-3 minutes
Spray onto or under tongue. Do not inhale.
Topical
Ointment/Patch
30-60 minutes
Used for prophylaxis. Apply to hairless area. Rotate sites. Remove patch daily for nitrate-free interval.
Oral (Swallowed)
Sustained-release capsule
20-45 minutes
Do not crush or chew. Used for long-term prophylaxis, not acute attacks.
Anatomy, Physiology & Pharmacology Points
First-Pass Metabolism: Drugs absorbed from the GI tract travel via the portal vein to the liver, where a significant portion may be metabolized before reaching systemic circulation. Sublingual route bypasses this.
Sublingual Mucosa: Highly vascular with thin epithelium, allowing rapid passive diffusion of lipid-soluble drugs like nitroglycerin directly into the bloodstream.
Nitrate Tolerance: Develops with continuous exposure. This is why transdermal patches are removed for 10-12 hours daily to provide a "nitrate-free interval."
Memory Tips
SL = Stop & Let dissolve: SubLingual means Stop talking, Let it dissolve.
The 3 Don'ts for SL NTG: Don't chew, Don't swallow, Don't drink water with it.
Rule of 3's for Acute Angina: 1 tablet, wait 5 minutes. Can repeat up to 3 times. If pain persists after 3 doses, it's an emergency (call 911).
High-Frequency NCLEX Topics
NCLEX loves to test medication administration routes, especially the specifics of sublingual nitroglycerin. Be ready for questions on: correct technique, patient education points, recognizing ineffective treatment (indicating unstable angina or MI), and managing side effects like headache and hypotension.
Watch Out for Question Variations!
Priority Action: "A patient takes sublingual nitroglycerin for chest pain. What should the nurse assess first?" (Answer: Relief of pain and vital signs, especially blood pressure for hypotension).
Patient Teaching Evaluation: "Which statement by the patient indicates understanding of nitroglycerin use?" (Correct: "I will place the pill under my tongue and let it dissolve." Incorrect: "I will take it with a sip of water.").
Storage: "How should the nurse instruct the patient to store nitroglycerin tablets?" (Answer: In the original dark glass bottle, tightly closed, away from heat and light. Do not transfer to a pillbox).
Nursing Clinical Practice GuideClinical Scenario: Mr. Johnson, 68, with a history of coronary artery disease (CAD), is admitted for observation. He reports occasional chest tightness with exertion (stable angina). He has a prescription for nitroglycerin 0.4 mg sublingual tablets PRN.
Nursing Intervention Strategy:
Assessment: When Mr. Johnson reports chest pain, immediately assess pain characteristics (PQRST), vital signs (especially BP), and administer oxygen if ordered/needed. Have him sit or lie down.
Administration: Open the dark glass bottle. Place one tablet under his tongue. Instruct him not to talk, chew, swallow, or drink water until the tablet is fully dissolved. Note the time.
Monitoring: Reassess pain level and vital signs after 5 minutes. If pain is unrelieved, repeat administration (second tablet). Monitor for therapeutic effect (pain relief) and side effects (headache, dizziness, hypotension).
Patient Education: Teach him the correct technique. Emphasize the "3-dose rule" and the need to call 911 if pain persists. Discuss storage, medication expiration (tablets lose potency in 3-6 months after opening), and the importance of carrying it at all times.
Patient Safety and Precautions:
Contraindication/Caution: Use with extreme caution if systolic BP is < 90 mmHg or if patient has taken phosphodiesterase-5 inhibitors (e.g., sildenafil/Viagra) within 24-48 hours (risk of severe, life-threatening hypotension).
Side Effect Management: Inform patient that a headache is common and indicates the drug is working. It often subsides with continued use. Hypotension can cause dizziness/lightheadedness - this is why sitting is crucial.
Nursing Procedure & Medication FlowStep-by-Step for Sublingual Nitroglycerin Administration:
1. Verify order and perform hand hygiene.
2. Identify patient using two identifiers.
3. Assess pain level (0-10 scale) and baseline vital signs.
4. Assist patient to a sitting or supine position.
5. Remove one tablet from the original container. Do not touch multiple tablets as moisture from hands can degrade them.
6. Instruct patient to lift tongue. Place tablet under the tongue.
7. Instruct patient to close mouth and breathe normally. Do not swallow saliva excessively until tablet dissolves (1-2 minutes).
8. Dispose of any unused tablet that falls out; do not return to bottle.
9. Document: Time administered, pain rating pre/post, vital signs, patient response, and teaching provided.
A Word from Your Senior Nurse
"Nitroglycerin is a lifeline drug for our cardiac patients. In clinical practice, I've seen patients try to chew it 'to make it work faster' or take it with water out of habit. Your clear, confident education in that moment is what ensures the drug works as intended. Remember, if a patient's chest pain isn't relieved by three sublingual nitroglycerin doses, you're no longer dealing with stable angina — you're likely looking at an acute coronary syndrome (ACS) like a myocardial infarction (MI). Your rapid recognition and escalation of care at that point is critical. On the NCLEX, they test these details because in real life, they save lives."
Sublingual Administration — A route of drug administration where medication is placed under the tongue to dissolve, allowing for rapid absorption directly into the bloodstream via the sublingual mucosa, bypassing the gastrointestinal tract and first-pass liver metabolism.
First-Pass Metabolism — The initial metabolism of an orally administered drug by the liver, via the portal vein, before it reaches the systemic circulation. This can significantly reduce the bioavailability of many drugs, which is why routes like sublingual or IV are used to bypass it.
Stable Angina (Angina Pectoris) — Chest pain or discomfort due to coronary heart disease, typically triggered by physical exertion or emotional stress and relieved by rest or nitroglycerin. It is predictable in pattern and indicates a temporary imbalance between myocardial oxygen supply and demand.
Vasodilation — The widening of blood vessels, which decreases vascular resistance and blood pressure. Nitroglycerin primarily causes venous dilation (reducing preload) and some arterial dilation (reducing afterload), thereby decreasing the heart's workload and oxygen demand.
Nitrate Tolerance — A phenomenon where continuous exposure to nitrates (e.g., from a transdermal patch worn 24/7) leads to a diminished therapeutic effect. It is managed by providing a daily nitrate-free interval (e.g., 10-12 hours patch-off period).