Nurse Kelly, a triage nurse encountered a client who complained of mid-sternal chest pain, dizziness, and diaphoresis. Which of the following nursing action should take priority?
A. Administer oxygen therapy via nasal cannula
B. Notify the physician
C. Complete history taking
D. Put the client on ECG monitoring
Correct Answer: A. Administer oxygen therapy via nasal cannula.
The priority goal is to increase myocardial oxygenation. Place the patient on a cardiac monitor, establish intravascular access (IV) access, give 162 mg to 325 mg chewable aspirin, clopidogrel, or ticagrelor (unless bypass surgery is imminent), control pain and consider oxygen (O2) therapy.
Option B: Patients with non-ST elevation myocardial infarction (NSTEMI) and unstable angina should be admitted for cardiology consultation and workup. Patients with stable angina may be appropriate for outpatient workup.
Option C: Carefully review the patient’s medical history for cardiac history, coagulopathies, and kidney disease. Ask about family history, especially cardiac, and ask about social histories like drug use and tobacco use.
Option D: These actions are also appropriate and should be performed immediately. Electrocardiogram (ECG) preferably in the first 10 min of arrival, (consider serial ECGs). Patients with ST-elevation on ECG patients should receive immediate reperfusion therapy either pharmacologic (thrombolytics) or transfer to the catheterization laboratory for percutaneous coronary intervention (PCI).
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