A nurse is caring for a patient who has just been admitted to the hospital with chest pain and shortness of breath. The patient has a history of coronary artery disease and hypertension. The nurse obtains vital signs, performs an electrocardiogram (ECG), and administers oxygen therapy as ordered by the physician. What is the next priority action for the nurse?

Choice A reason:

Identifying the client's health problems is not the first step in formulating a diagnostic statement. The nurse needs to gather and analyze the assessment data before identifying the health problems.

Choice B reason:

Clustering the assessment data is the first step in formulating a diagnostic statement. The nurse groups related data together to identify patterns and relationships that indicate a human response to health conditions or life processes.

Choice C reason:

Validating the data with the client is not the first step in formulating a diagnostic statement. The nurse needs to cluster the data first and then validate it with the client to ensure accuracy and completeness.

Choice D reason:

Prioritizing the health problems is not the first step in formulating a diagnostic statement. The nurse needs to cluster the data first and then identify the health problems before prioritizing them.

Choice A reason:

Administering nitroglycerin sublingually as ordered is the next priority action for the nurse because nitroglycerin is a medication that relaxes the heart arteries and improves blood flow to the heart muscle, which can relieve chest pain and shortness of breath caused by coronary artery disease. Nitroglycerin can also lower blood pressure, which can help reduce the workload of the heart and prevent further damage to the heart muscle. Nitroglycerin is a fast-acting medication that should be given as soon as possible after chest pain occurs or is suspected.

Choice B reason:

Obtaining a complete health history from the patient is not the next priority action for the nurse because it is not an urgent intervention that can address the patient's immediate needs. A complete health history can provide valuable information about the patient's risk factors, past medical history, medications, allergies, and family history, but it can also take a long time to obtain and may not be feasible if the patient is in pain or distress. A complete health history can be obtained later after the patient's condition is stabilized and more urgent interventions are done.

Choice C reason:

Educating the patient about lifestyle modifications is not the next priority action for the nurse because it is not an acute intervention that can relieve the patient's symptoms or prevent further complications. Lifestyle modifications such as quitting smoking, eating a healthy diet, exercising regularly, managing stress, and controlling blood pressure and cholesterol levels are important for preventing or managing coronary artery disease in the long term, but they do not have an immediate effect on the patient's condition. Educating the patient about lifestyle modifications can be done later after the patient's condition is improved and the patient is ready to learn.

Choice D reason:

Preparing the patient for cardiac catheterization is not the next priority action for the nurse because it is not a definitive intervention that can confirm or rule out coronary artery disease or other causes of chest pain and shortness of breath. Cardiac catheterization is a diagnostic procedure that involves inserting a thin tube into an artery in the groin or arm and advancing it to the heart to inject contrast dye and take X-ray images of the heart and blood vessels. Cardiac catheterization can help identify blockages or narrowing in the coronary arteries that may cause chest pain and shortness of breath, but it also carries some risks such as bleeding, infection, allergic reaction, kidney damage, or heart attack. Cardiac catheterization may be ordered by the physician after other tests such as ECG, blood tests, or.