# A nurse is caring for a client with acute myocardial infarction. Which of the following actions is the highest priority?

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> subject: Adult Health

## 문제

A nurse is caring for a client with acute myocardial infarction. Which of the following actions is the highest priority?

## 보기

1. Administer prescribed pain medication to relieve chest pain
2. Monitor cardiac rhythm and assess for life-threatening arrhythmias **✔ 정답**
3. Obtain a 12-lead electrocardiogram
4. Educate the client about lifestyle modifications to prevent future cardiac events

**정답: 2**

## 해설

Continuous cardiac monitoring for life-threatening arrhythmias is the highest priority in acute MI, as arrhythmias are the leading cause of death in the first 24-48 hours. Other interventions like pain management and ECG are important but secondary to immediate life threats.

## 심화 해설

Clinical Reasoning and Priority Setting

The correct answer is to monitor cardiac rhythm and assess for life-threatening arrhythmias. In the immediate management of a client with an acute myocardial infarction (AMI), the highest nursing priority is continuous surveillance for lethal arrhythmias, which are the most common cause of early death following coronary occlusion. This action directly addresses the risk of sudden cardiac arrest, aligning with the fundamental principle of the ABCs (Airway, Breathing, Circulation) where maintaining a perfusing rhythm is critical for circulation.

Why Monitoring Takes Precedence Over Other Actions

While all listed interventions are important components of comprehensive care, they are prioritized based on the immediacy of the threat to life. The period immediately following an AMI is one of electrical instability. Myocardial ischemia and necrosis disrupt the cardiac cell membrane's integrity and ion transport systems, creating a highly arrhythmogenic substrate. Ventricular tachycardia (VT) and ventricular fibrillation (VF) can occur without warning and lead to cardiac arrest within minutes. The 2025 Korean Guidelines for Cardiopulmonary Resuscitation emphasize a system of readiness for sudden cardiac arrest, which begins with recognizing the patient at risk and ensuring immediate access to defibrillation [1]. A nurse's continuous monitoring is the first and most critical link in this survival chain, as it allows for the instant detection of a lethal rhythm and the prompt initiation of life-saving interventions like defibrillation.

The other options, though valid, are secondary in this acute phase. Administering pain medication (Option 1) is crucial for patient comfort and reducing myocardial oxygen demand, but it does not prevent the immediate, catastrophic event of a lethal arrhythmia. Obtaining a 12-lead electrocardiogram (Option 3) is a vital diagnostic tool to confirm the infarction, locate the affected area, and guide reperfusion therapy, yet it provides only a single snapshot in time and does not offer the continuous, real-time surveillance required for arrhythmia detection. Educating the client about lifestyle modifications (Option 4) is an essential component of secondary prevention and discharge planning but is a non-urgent task that is inappropriate during the unstable, acute phase of care.

Connecting Nursing Surveillance to Patient Outcomes

The critical nature of intensive monitoring is further supported by the concept that nursing process indicators, such as monitoring intensity and assessment frequency, are proxy markers for clinical acuity and surveillance . A study examining patients with AMI undergoing percutaneous coronary intervention (PCI) found that documentation-derived nursing process indicators, which reflect the intensity of bedside monitoring and assessment, are associated with in-hospital outcomes . A higher frequency of nursing assessments and continuous monitoring signifies a heightened state of vigilance for a patient at high risk for decompensation. This evidence reinforces that the act of monitoring is not a passive task but an active, high-level nursing function that directly correlates with patient safety and the early detection of complications, including life-threatening arrhythmias. The nurse at the bedside serves as the primary detector of electrical catastrophe, making this the non-negotiable, highest-priority action.References (research sources)

- [1]2025 Korean Guidelines for Cardiopulmonary Resuscitation: Part 3. Adult basic life support.GuidelineJang YS, Cho GC, Cho Y, Na SG, Kim DK, Kim TY, Sohn Y, Shim G, Jung YH, Oh Y, Youn CS, Lee MJ, Lee J, Lee CH, Jang Y, Chung SP, Cha KC, Heo JS, Hwang SO. (2026) · DOI: 10.15441/ceem.26.095

## 임상 시나리오

Immediate Post-AMI MonitoringPrioritizing Life-Threatening Arrhythmia Detection
The highest priority in the acute phase of myocardial infarction is continuous cardiac rhythm monitoring. The ischemic myocardium is electrically unstable, and lethal arrhythmias like ventricular tachycardia or ventricular fibrillation are the most common cause of early death. Early detection allows for immediate defibrillation, which is critical for survival.

Nurses must ensure the monitor's alarms are on, audible, and set appropriately. Establish a clear baseline rhythm and continuously observe for changes such as premature ventricular contractions, which may herald more serious rhythms. Keep emergency equipment, including a defibrillator, immediately accessible at the bedside.

Clinical AlertDo not delay defibrillation to obtain a 12-lead ECG if a patient develops a pulseless lethal rhythm. Immediate high-quality CPR and rapid defibrillation are the top priorities, taking precedence over diagnostic procedures.

## 핵심 개념

- **Acute Myocardial Infarction** — Irreversible necrosis of heart muscle secondary to prolonged ischemia, creating an electrically unstable substrate prone to lethal arrhythmias.
- **Lethal Arrhythmias** — Rhythms such as ventricular tachycardia and ventricular fibrillation that result in ineffective cardiac output and can rapidly lead to cardiac arrest.
- **Priority Setting** — A clinical decision-making framework using principles like the ABCs to address the most immediate threats to life before other interventions.

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