Safe, Effective Care Environment
73. A client, admitted to the emergency department with a myocardial infarction (MI), is experiencing chest pain and becomes profusely diaphoretic and apprehensive. What should be the initial intervention by the RN?
. Increase the nasal oxygen from 2 L/min to 6 L/min.
. Check the troponin and myoglobin levels on the chart.
. Give the prn dose of morphine sulfate 3 mg IV push.
. Get a 12-lead ECG.
Test-Taking Tip
Look at the symptom in the stem (pain); choose an option (analgesic) that relates to pain management.
Content Area: Adult Health, Cardiovascular; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Safe and Effective Care Environment/Management of Care/Establishing Priorities
Safe, Effective Care Environment
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Answer 1 is incorrect because increasing the oxygen to 6 L/min is unnecessary. The usual rate of oxygen is 2 to 4 L/min to maintain the pulse oximeter reading at 96% to 98%. Answer 2 is incorrect because, although these levels are important data, the urgency of the client's situation is comfort and pain management while increasing coronary artery perfusion. Answer 3 is correct because morphine sulfate is given for chest pain at a rate of 1 mg/min repeated every 5 minutes as needed to block pain perception. However, in myocardial ischemia it decreases anxiety and oxygen demand as it promotes vasodilation. Answer 4 is incorrect because it is not the priority. However, this test will probably be ordered if the client's symptoms suggest an extension of the infarction.