The nurse is caring for an adult client who presents to the emergency department with a report of difficulty breathing and the feeling of an elephant sitting on the chest. Which interventions are an emergent priority? Select all that apply.
a. Obtain vital signs
b. Obtain an ECG
c. Ask the client to cough
d. Auscultate the lungs
e. Assess for recent IV drug use
a. Obtain vital signs
b. Obtain an ECG
rationale: The nurse will initiate vital signs right away on this client. The main concerns for anyone with pain in the chest area is a heart issue (myocardial infarction) or lung issue (Pulmonary Embolism). The nurse and other healthcare team members will be simultaneously calling for an EKG, assessing vital signs, and obtaining IV access.
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