While close family members are visiting, a patient has a respiratory arrest, and resuscitation is started. Which action by the nurse is best?

Administer furosemide IV: Furosemide is a diuretic used to manage fluid overload, which is not the primary concern in this scenario. The client presents with chest pain suggestive of a cardiac event, so other interventions should take priority.

Prepare the client for intubation: Intubation is not indicated at this stage as the patient is conscious, has a respiratory rate of 18/min, and there is no immediate indication of airway compromise. Oxygen therapy is more appropriate.

Obtain the client’s full family history: While obtaining a full family history is important for a comprehensive assessment, it is not a high priority in the acute management of this client who presents with symptoms suggestive of a myocardial infarction (MI).

Administer O2 to maintain oxygen saturation greater than 90%: The client’s oxygen saturation is 88%, which is below the desired level. Administering oxygen to maintain saturation greater than 90% is a high-priority intervention to improve oxygenation.

Apply continuous ECG monitoring: Continuous ECG monitoring is essential in this scenario to monitor for arrhythmias and assess for ongoing ischemia, given the client’s chest pain, irregular pulse, and the high likelihood of an acute coronary syndrome.

Obtain vascular access: Establishing vascular access is a high priority to ensure the ability to administer medications, fluids, and for potential blood draws, especially in an emergency setting where rapid intervention may be necessary.

A. Numbness and tingling in the left hand could indicate compromised blood flow or nerve damage, potentially due to the arterial line, requiring immediate assessment and intervention.

B. Slight bloody drainage is a common finding and typically does not require immediate action.

C. A dressing beginning to lift should be addressed to maintain a sterile environment but is not an emergency.

D. Slight redness at the insertion site may indicate mild irritation or early signs of infection, but it does not require immediate intervention compared to the potential vascular or nerve compromise suggested by numbness and tingling.