A patient is brought into the emergency department (ED) by family members who tell the nurse the patient grabbed his chest and complained of substernal chest pain that feels like something is sitting on his chest
The pain radiates to the jaw and the left shoulder. The nurse notes the patient is diaphoretic and short of breath. What is the nurse's priority action?
A) Notify the physician of a probable MI
B) Take vital signs
C) Give sublingual nitroglycerin
D) Administer oxygen
Ans: D
Feedback: Myocardial ischemia is a condition in which heart muscle cells receive less oxygen than needed. The nurse's priority action would be to provide more oxygen to the myocardium. Once oxygen has been started, a cardiac monitor is attached to the patient, vital signs are taken, and sublingual nitroglycerin given. The physician would be notified by a staff member not involved with the patient's care.
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Fill in the blank(s) with the appropriate word(s).