A client presents to the emergency department with complaints of severe chest pain. Which actions should the nurse implement first?

Call the cardiac catheterization lab and give report to transfer the client.

Administer atenolol 25 mg po.

Assess vital signs and obtain a 12-lead EKG.

Call a rapid response.

Answer and Explanation

The Correct Answer is C

A. Call the cardiac catheterization lab and give report to transfer the client: This action is premature. Before considering a transfer to the catheterization lab, the nurse should first assess the patient to determine the severity and nature of the chest pain, which can help identify if the pain is related to a cardiac issue, such as an acute myocardial infarction (MI), and to guide further interventions.

B. Administer atenolol 25 mg po: While beta-blockers like atenolol may be part of the treatment plan for patients with chest pain, administering oral medication (PO) is not appropriate in an emergency situation, especially if the patient is experiencing severe chest pain. Immediate action should focus on assessment and stabilizing the patient before administering medications.

C. Assess vital signs and obtain a 12-lead EKG:The first priority is to assess the patient’s condition. Vital signs provide important information about the patient's hemodynamic status, and obtaining a 12-lead EKG is crucial for diagnosing acute myocardial infarction (MI) or other heart-related conditions. The EKG will help identify any abnormal rhythms or signs of ischemia, which will guide the treatment plan.

D. Call a rapid response: While calling a rapid response may be necessary if the patient's condition worsens or if they become unstable, the first step should be to assess the patient thoroughly. If the patient's condition deteriorates during the assessment, a rapid response may be called.

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Correct Answer is A

Explanation

A. NSTEMI (Non-ST-Elevation Myocardial Infarction) refers to a heart attack where there is partial blockage or damage to the heart muscle but less severe than in STEMI (ST-Elevation Myocardial Infarction). The damage in NSTEMI typically affects a smaller area of the heart muscle, and it may not involve a full-thickness injury like in STEMI. This response provides the client with a clear, understandable explanation of their condition.

B. This statement is incorrect because NSTEMI is not the same as angina. Angina is chest pain due to temporary lack of blood flow to the heart, while NSTEMI involves actual damage to the heart muscle due to a more significant reduction in blood flow, even if the heart attack is less severe than a STEMI.

C. While NSTEMI is a serious condition, it does not automatically require open heart surgery. Treatment often involves medications (like antiplatelets or anticoagulants) and procedures like angioplasty or stenting to address the blockage, not necessarily surgery.

D. This response is somewhat misleading. Cardiac catheterization may be used to assess the severity and location of the blockage, but it is not always used to directly correct the problem. Procedures such as angioplasty or stent placement may follow the catheterization, but not all patients with NSTEMI will need immediate intervention.

A. Decrease in blood pressure. B. Decrease in cardiac dysrhythmias. C. Relief of chest pain. D. Decrease in heart rate.

Correct Answer is C

Explanation

A. Decrease in blood pressure: Nitroglycerin can cause vasodilation, leading to a decrease in blood pressure. However, the goal of administering nitroglycerin during an acute myocardial infarction (MI) is not primarily to lower blood pressure, but to improve oxygen supply to the heart and relieve pain. A decrease in blood pressure may occur as a side effect but is not the primary indication for its use.

B. Decrease in cardiac dysrhythmias: While nitroglycerin may help reduce myocardial oxygen demand, it is not specifically aimed at treating or preventing cardiac dysrhythmias. The primary action of nitroglycerin is to relieve chest pain by vasodilation and improving blood flow to the heart muscle.

C. Relief of chest pain: The primary effect of nitroglycerin in the setting of an acute MI is to relieve chest pain (angina). It works by dilating coronary arteries and improving blood flow to the heart muscle, thus reducing ischemia and relieving pain.

D. Decrease in heart rate: Nitroglycerin may have a secondary effect of reducing heart rate due to a reduction in preload and afterload, but this is not the primary objective. Nitroglycerin’s main goal is to relieve chest pain by improving oxygen supply to the heart muscle.

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