23. A client comes to an emergency department reporting chest pain; vital signs are: BP 110/68 mm Hg, P 110 and irregular, R 24, and pulse oximetry 88%. Which interventions should a nurse perform first? Prioritize the nurse's actions by placing each intervention in the correct sequence.
. Give morphine 10 mg as ordered.
. Start O2 6 L per mask.
. Give nitroglycerin (NTG) sublingual gr 1/150.
. Run an ECG strip
Test-Taking Tip
When all of the options are correct, think of the priorities—prevent damage from hypoxia, gather data, and treat.
Content Area: Adult Health, Cardiovascular; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems
. . . .
Supplemental oxygen is the first action to prevent any cardiac damage from hypoxia. The oxygen can be started while continuing the client assessment and applying the ECG electrodes. The ECG leads should be applied second, to assess for any life-threatening arrhythmias. NTG is often given with an antacid for unexplained chest pain. It would be the third action after determining the cardiac rhythm. NTG can change the ECG pattern. Morphine may eventually be given if the pain is not relieved by the antacid or NTG. This would be the fourth action.