# A nurse is caring for a 58-year-old male client who presents to the emergency department with substernal chest pain radiating to his left arm and jaw, started 30 minutes ago while climbing stairs, described as crushing and severe (8/10), and appearing anxious and diaphoretic. Which nursing intervention should be implemented first? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=176940 > language: ko > subject: Adult Health ## 문제 A nurse is caring for a 58-year-old male client who presents to the emergency department with substernal chest pain radiating to his left arm and jaw, started 30 minutes ago while climbing stairs, described as crushing and severe (8/10), and appearing anxious and diaphoretic. Which nursing intervention should be implemented first? ## 보기 1. Obtain a 12-lead electrocardiogram immediately 2. Place the client in a comfortable position and administer oxygen **✔ 정답** 3. Administer nitroglycerin sublingually as prescribed 4. Draw blood for cardiac enzyme levels promptly **정답: 2** ## 해설 For acute chest pain, priority is to optimize oxygenation and reduce cardiac workload by positioning and oxygen administration, as per ABC principles. Other interventions like ECG or nitroglycerin are critical but may require orders or follow initial stabilization. ## 심화 해설 Understanding the Clinical Scenario The client presents with classic signs of an acute coronary syndrome (ACS): substernal chest pain with radiation to the left arm and jaw, a crushing quality, and associated autonomic symptoms (anxiety, diaphoresis). This presentation indicates a critical imbalance between myocardial oxygen supply and demand, leading to ischemia. The immediate priority is not to diagnose or definitively treat, but to intervene in ways that rapidly improve this supply-demand mismatch and prevent further myocardial damage. Analysis of the Priority Intervention The correct first action is to place the client in a comfortable position and administer oxygen. This intervention directly addresses the fundamental pathophysiological problem—myocardial hypoxia—and is a foundational, low-risk step that supports all subsequent therapies. - Positioning: Placing the client in a semi-Fowler's or upright position reduces venous return (preload) and decreases the workload on the heart. This simple action can immediately lower myocardial oxygen consumption, which is critically elevated during an ischemic event. - Oxygen Administration: The client's anxiety and diaphoresis suggest increased sympathetic nervous system activity, which raises heart rate and systemic vascular resistance, further increasing myocardial oxygen demand. While current guidelines reserve supplemental oxygen for patients with hypoxia (SpO2 < 90%), in the immediate, undifferentiated emergency setting, a nurse's initial response for a patient with suspected ACS and signs of distress includes applying oxygen to ensure maximal oxygen-carrying capacity of the blood, directly targeting the supply side of the imbalance. This intervention aligns with the core principles of evidence-based nursing for acute chest pain. A study on improving the pre-examination process for acute chest pain emphasizes that a structured, immediate nursing response is crucial for reducing treatment delays and improving outcomes . The first link in this chain is a rapid clinical assessment and the initiation of supportive measures like positioning and oxygen to stabilize the patient before more advanced diagnostics or pharmacology. Why Other Options Are Not the First Priority - Option 1: Obtain a 12-lead electrocardiogram immediately. While an ECG is the single most critical diagnostic test for ACS and should be performed within 10 minutes of arrival, it is an assessment tool, not a treatment. The immediate priority is a stabilizing intervention that can be performed concurrently or seconds before the ECG is set up. The nurse can place the patient in a comfortable position and apply oxygen while another team member prepares the ECG machine, making this a simultaneous but not a first independent nursing action. - Option 3: Administer nitroglycerin sublingually as prescribed. Nitroglycerin is a key pharmacological agent that reduces preload and dilates coronary arteries, directly addressing the oxygen supply-demand imbalance. However, it is a prescribed medication that requires a confirmed diagnosis and ruling out contraindications, such as recent phosphodiesterase inhibitor use or severe hypotension. It is a secondary step after initial stabilization and assessment. - Option 4: Draw blood for cardiac enzyme levels promptly. Cardiac enzymes, particularly high-sensitivity troponin, are essential for diagnosing myocardial infarction. However, their diagnostic value is time-dependent; an initial level may be normal in the first few hours of an infarction. This is a crucial but non-urgent diagnostic task compared to the immediate physiological need to improve oxygenation and reduce cardiac workload. Connecting to Holistic Patient Care The Roy Adaptation Model, when applied to ACS patients, views the individual as a biopsychosocial being constantly adapting to environmental stimuli, in this case, the focal stimulus of myocardial ischemia . The interventions of positioning and oxygen administration are physiological mode regulators that help the patient's adaptive system cope with the crisis. By reducing the physiological workload and improving oxygenation, the nurse is directly facilitating the patient's adaptive response, which is the immediate goal before introducing more complex pharmacological or interventional treatments. This holistic stabilization is the bedrock upon which all other care, including risk stratification for complications like those seen in frail patients , is built. ## 임상 시나리오 Initial Nursing Actions for Suspected ACSPrioritizing comfort and oxygenation before diagnostics The first priority for a client with crushing chest pain and diaphoresis is to reduce myocardial oxygen demand. Position the client in a semi-Fowler's or upright position to decrease venous return (preload) and cardiac workload. Administer oxygen to maintain SpO2 ≥ 90%. In the immediate emergency, supplemental oxygen helps compensate for potential hypoxia driven by increased sympathetic activity and anxiety. CautionDo not delay positioning and oxygen for a 12-lead ECG or blood draws. These diagnostic steps follow the initial stabilization. Nitroglycerin is administered after ensuring a stable position and oxygen are in place. ## 핵심 개념 - **Acute Coronary Syndrome (ACS)** — A spectrum of conditions including unstable angina and myocardial infarction, caused by a sudden reduction in blood flow to the heart. - **Myocardial Oxygen Demand** — The amount of oxygen the heart muscle requires to function; increased by factors like high heart rate, contractility, and ventricular wall tension. - **Preload** — The degree of stretch of the cardiac muscle fibers at the end of diastole, directly related to venous return to the heart. - **Semi-Fowler's Position** — A position where the head of the bed is elevated 30 to 45 degrees, which reduces venous return and decreases cardiac workload. ## 같은 주제 문제 - [A 45-year-old client with a history of coronary artery disease is admitted to the emergenc…](https://mymerci.kr/pages/nclex_q.php?qn_id=176935) - [A 65-year-old female patient presents to the emergency department with chest pain. 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