A nurse is assessing a patient who was admitted to the emergency room for chest pain. Which of the following interventions should the nurse prioritize?

Rationale:

A. Hemoptysis (coughing up blood) is not a common or expected side effect of warfarin therapy.

It may indicate a serious complication and should be reported to a healthcare provider immediately.

B. Warfarin increases the risk of bleeding, so it is important for the client to avoid activities or clothing that may increase the risk of injury or bleeding, such as tight or restrictive clothing.

C. Epistaxis (nosebleeds) can occur as a side effect of warfarin therapy due to its anticoagulant effects. While it is a potential side effect, it is not an expected outcome and should be reported to the healthcare provider.

D. Nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided while taking warfarin because they can increase the risk of bleeding due to their antiplatelet effects. If a headache occurs, the client should consult their healthcare provider for appropriate pain management options.

Rationale:

A. Completing an electrocardiogram (ECG) is a priority in assessing a patient with chest pain to evaluate for signs of acute myocardial infarction or other cardiac abnormalities.

B. Obtaining a C-reactive protein level may be useful in certain situations to assess inflammation, but it is not a priority in the acute management of chest pain.

C. Administering an anti-hypertensive medication is not a priority unless the patient's blood pressure is significantly elevated and causing acute symptoms.

D. Completing an echocardiogram may be indicated later in the assessment process but is not typically performed immediately in the emergency room for evaluation of chest pain.