A patient who arrives in the emergency department complaining of squeezing substernal pain that radiates to the left shoulder and jaw also complains of nausea, diaphoresis, and shortness of breath. What should the nurse do?
A) Complete the patient's registration information, perform an electrocardiogram, gain IV access, and take vital signs.
B) Alert the cardiac catheterization team, administer oxygen, attach a cardiac monitor, and notify the physician.
C) Gain IV access, give sublingual nitroglycerin, and alert the cardiac catheterization team.
D) Administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin.
Ans: D
Feedback: Cardiac chest pain is caused by myocardial ischemia. Administering supplemental oxygen increases the myocardial oxygen supply. Cardiac monitoring will help detect life-threatening arrhythmias. The nurse must ensure that the patient isn't hypotensive before giving sublingual nitroglycerin for chest pain. Registration information may be delayed until the patient is stabilized. Alerting the cardiac catheterization team before completing the initial assessment is premature.
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