# A nurse is caring for a client with acute myocardial infarction. Which nursing intervention should be the priority?

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## 문제

A nurse is caring for a client with acute myocardial infarction. Which nursing intervention should be the priority?

## 보기

1. Administer prescribed oxygen therapy and monitor oxygen saturation continuously **✔ 정답**
2. Obtain a complete set of vital signs every 15 minutes
3. Encourage the client to perform deep breathing exercises
4. Assess the client's understanding of the cardiac catheterization procedure

**정답: 1**

## 해설

Oxygen therapy is the priority for acute MI to ensure tissue oxygenation and reduce cardiac workload. Other options are important but less urgent than addressing hypoxia.

## 심화 해설

Clinical Context and Priority Setting

In the hyperacute phase of an acute myocardial infarction (AMI), the immediate pathophysiological concern is the imbalance between myocardial oxygen supply and demand. Occlusion of a coronary artery leads to ischemia, which can rapidly progress to necrosis if perfusion is not restored or oxygen demand is not minimized. The nurse’s priority is to intervene in ways that directly support oxygen delivery to the jeopardized myocardium and prevent further decompensation.

Analysis of the Correct Answer

Administering prescribed oxygen therapy and continuously monitoring oxygen saturation is the priority intervention. In the context of AMI, hypoxemia can exacerbate ischemia by further reducing the oxygen content of blood delivered to the already compromised heart muscle. The evidence-based nursing processes for acute chest pain emphasize the critical role of immediate oxygenation assessment and intervention as part of the initial stabilization bundle [1][2]. Continuous monitoring allows the nurse to detect downward trends in saturation early, which is essential because a drop in SpO₂ below 90% can significantly worsen cardiac workload and extend the infarct zone. This intervention directly addresses the physiological crisis of inadequate tissue oxygenation.

Why the Other Options Are Not the Priority

- Option 2: Obtaining vital signs every 15 minutes is a necessary component of ongoing assessment, but it is a data-gathering action. It does not, by itself, correct a life-threatening oxygen deficit. While frequent monitoring is part of optimized emergency nursing protocols to track response to treatment [1], the immediate therapeutic action to support oxygenation takes precedence.

- Option 3: Encouraging deep breathing exercises is a low-acuity intervention aimed at preventing pulmonary complications in stable patients. In the setting of an AMI, active deep breathing increases intrathoracic pressure and venous return, which can paradoxically increase myocardial wall stress and oxygen demand. This is not appropriate during the acute ischemic event and is not supported by the streamlined, stabilization-focused processes described in the literature [1][2].

- Option 4: Assessing understanding of a cardiac catheterization procedure is an important psychosocial and educational task, but it falls under secondary or tertiary priorities once the patient is hemodynamically stable. The optimized care models for acute chest pain focus on reducing door-to-treatment times through rapid clinical intervention, not on detailed procedural teaching during the initial crisis [1][2]. Delaying oxygen therapy to provide education would violate the principle of addressing physiological needs first.

Integration of Evidence into Practice

The optimized emergency nursing care processes highlighted in the referenced studies underscore a systematic approach to acute chest pain that prioritizes rapid, protocol-driven clinical interventions [1][2]. These protocols are designed to minimize delays in therapies that directly impact survival, such as oxygen administration when hypoxemia is present or suspected. The nurse’s role in this streamlined workflow is to execute these standing medical directives immediately, understanding that maintaining adequate oxygen saturation is a foundational step that supports all subsequent treatments, including reperfusion strategies.References (research sources)

- [1]Effects of optimizing emergency nursing care process on success rate of rescue and incidence of adverse reactions in patients with acute chest pain.Research articleZhu H, Ding D. (2025) · DOI: 10.3389/fmed.2025.1727151

- [2]Application of Continuous Improvement of Pre-Examination Process Based on Evidence-Based Nursing Concept in Acute Chest Pain of Adults.Research articleGan Q, Yao R. (2026) · DOI: 10.1155/emmi/8401158

## 임상 시나리오

Oxygen Therapy in Acute MIPrioritizing Interventions for Myocardial Oxygen Delivery
The immediate goal in acute myocardial infarction is to correct the myocardial oxygen supply-demand imbalance. Administering oxygen and monitoring SpO₂ are part of the initial stabilization bundle.

Initiate oxygen therapy if SpO₂ is below 90% or if the patient shows signs of respiratory distress. Continuous monitoring detects early decompensation.

CautionRoutine high-flow oxygen in normoxic patients is no longer recommended and may cause vasoconstriction. Titrate to maintain SpO₂ at or above 90%.

## 핵심 개념

- **Myocardial Oxygen Supply-Demand Imbalance** — The core pathophysiological problem in AMI where coronary artery occlusion reduces oxygen supply while the heart's demand remains, leading to ischemia.
- **Hypoxemia** — An abnormally low concentration of oxygen in the blood (SpO2 < 90%), which can worsen myocardial ischemia and extend the infarct zone.
- **Initial Stabilization Bundle** — A set of evidence-based, time-sensitive interventions for acute chest pain/AMI, including oxygenation, aspirin, nitroglycerin, and pain management.

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