A patient who develops chest pain says the pain is a 9 on a scale of 0 to 10. Which of the following actions should the nurse take?
a. Administer aspirin.
b. Listen to breath sounds.
c. Notify the RN.
d. Apply telemetry.
ANS: C
The RN needs to be informed immediately so the physician can be notified for orders. Breath sounds will not clarify the patient's clinical status because chest pain is a symptom of an acute myocardial infarction (MI). Vital signs, oxygen, and nitroglycerin are appropriate interventions. Telemetry may also be used but is not the highest priority at this time.
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