# A nurse is caring for a client with stable angina who reports chest pain during mild exertion. Which nursing intervention should be implemented first?

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> subject: Adult Health

## 문제

A nurse is caring for a client with stable angina who reports chest pain during mild exertion. Which nursing intervention should be implemented first?

## 보기

1. Administer prescribed nitroglycerin sublingually as ordered
2. Monitor the client's heart rate and rhythm continuously
3. Instruct the client to stop all activity and assume a position of comfort **✔ 정답**
4. Administer oxygen at 2-4 L/min via nasal cannula as needed

**정답: 3**

## 해설

For stable angina, immediate priority is to reduce myocardial oxygen demand by stopping activity and positioning for comfort, as this quickly decreases heart workload. Other interventions like nitroglycerin or ECG are important but follow after initial stabilization.

## 심화 해설

Understanding the Priority: Initial Nursing Action for Stable Angina

When a client with stable angina reports chest pain during mild exertion, the nurse must prioritize interventions based on the physiological goal of reducing myocardial oxygen demand. Stable angina occurs due to a fixed narrowing of coronary arteries, leading to an imbalance between oxygen supply and demand during increased cardiac workload. The immediate, non-pharmacological step is to decrease that workload.

Why Stopping Activity is the First Intervention

The correct answer is to instruct the client to stop all activity and assume a position of comfort. This action directly addresses the pathophysiology of the pain. Physical exertion increases heart rate, blood pressure, and myocardial contractility, all of which raise myocardial oxygen consumption. When a fixed coronary stenosis prevents a corresponding increase in oxygen supply, ischemia and chest pain result. By stopping activity and resting, the nurse immediately reduces the heart's workload and oxygen demand, which can alleviate ischemia and pain even before medication is administered. This aligns with the core principles of cardiac rehabilitation and exercise management for patients with coronary heart disease (CHD), where activity is carefully titrated to avoid exceeding the ischemic threshold. Research into cardiac rehabilitation protocols, such as those comparing different walking intensities for patients after percutaneous intervention, highlights the critical need to balance exercise with adequate rest to prevent adverse events and improve long-term adherence .

Analyzing the Other Options

While the other interventions are important components of care for stable angina, they are not the first priority.

- Administering nitroglycerin: This is a key pharmacological intervention that dilates coronary arteries and reduces preload, thus lowering oxygen demand and increasing supply. However, it should be administered after the client has stopped the exertional activity that precipitated the pain. Giving nitroglycerin while the client continues to exert themselves would work against the drug's therapeutic goal.

- Monitoring heart rate and rhythm: Continuous monitoring is essential for assessing the client's response to pain and treatment, and for detecting dysrhythmias. However, it is an assessment and surveillance measure, not an intervention that directly halts the ongoing ischemic process. The immediate need is to stop the insult (exertion).

- Administering oxygen: Current guidelines recommend oxygen therapy only if the client exhibits signs of hypoxemia, such as dyspnea or an SpO2 below 90%. Routine administration of oxygen in the absence of hypoxemia has not been shown to be beneficial and may even cause vasoconstriction. Therefore, it is not the universal first step for all clients with stable angina.

Connecting to Comprehensive Nursing Management

This initial, non-pharmacological intervention is a cornerstone of a broader nursing management model. Effective care for patients with CHD, often complicated by comorbidities like diabetes, extends beyond acute episodes. A multidisciplinary collaborative nursing approach has been shown to improve health-promoting behaviors and psychological status, which are vital for long-term secondary prevention . The nurse's role in the acute moment—teaching the client to recognize the pain, stop the provoking activity, and rest—is the first step in empowering the client with self-management skills that are reinforced through structured cardiac rehabilitation programs. These programs, which carefully prescribe exercise intensity, are designed to improve cardiorespiratory endurance safely, directly addressing the deconditioning and fear of activity that can accompany a CHD diagnosis . The goal is not just to treat an anginal episode but to prevent future ones, a concept that is also central to defining and avoiding delayed or missed diagnoses of chronic coronary syndromes, ensuring patients receive timely and appropriate management strategies .

## 임상 시나리오

Clinical Practice Guide: Immediate Response to Stable Angina

When a patient with known stable angina reports chest pain during mild exertion, the nurse's immediate priority is to reduce myocardial oxygen demand. The first and most critical non-pharmacological intervention is to instruct the patient to **stop all activity and assume a position of comfort** (usually semi-Fowler's or upright). This action directly decreases heart rate, blood pressure, and contractility, interrupting the ischemic cascade.

Following this initial step, the nurse should perform a focused assessment including pain characteristics (PQRST), vital signs, and oxygen saturation. If pain is unrelieved after 1-2 minutes of rest, administer prescribed sublingual nitroglycerin per protocol, reassessing pain and vital signs every 5 minutes. Routine oxygen administration is not indicated unless oxygen saturation is below 90% or the patient exhibits signs of respiratory distress, as it may cause unnecessary vasoconstriction.

Continuous cardiac monitoring should be initiated to detect any rhythm changes or ST-segment shifts. Document the sequence of interventions, the patient's response, and notify the provider if pain persists after three nitroglycerin doses or if the character of pain changes, as this may indicate unstable angina or myocardial infarction.

## 핵심 개념

- **Stable Angina** — Chest pain or discomfort caused by myocardial ischemia due to a fixed narrowing of coronary arteries, typically triggered by exertion or stress and relieved by rest or nitroglycerin.
- **Myocardial Oxygen Demand** — The amount of oxygen the heart muscle requires to function, determined by heart rate, contractility, and ventricular wall tension; increasing demand in the setting of limited supply causes ischemia.
- **Ischemia** — An inadequate blood supply to an organ or tissue, often due to obstruction of arterial inflow, leading to a deficiency of oxygen and nutrients.
- **Cardiac Workload** — The total burden placed on the heart, primarily influenced by the rate-pressure product and the volume of blood pumped; reducing it is a key goal in managing angina.
- **Sublingual Nitroglycerin** — A rapid-acting vasodilator administered under the tongue to relieve acute angina by reducing preload and afterload, thereby decreasing myocardial oxygen demand.

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