# A nurse is caring for a 65-year-old female client with stable angina who reports substernal chest pain rated 6/10 with radiation to the left arm during ambulation. Which nursing intervention should be implemented first?

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> subject: Adult Health

## 문제

A nurse is caring for a 65-year-old female client with stable angina who reports substernal chest pain rated 6/10 with radiation to the left arm during ambulation. Which nursing intervention should be implemented first?

## 보기

1. Administer prescribed sublingual nitroglycerin
2. Check the client's medication history for recent changes
3. Assess vital signs and oxygen saturation
4. Instruct the client to sit down and rest immediately **✔ 정답**

**정답: 4**

## 해설

The immediate priority is to reduce myocardial oxygen demand by having the client rest, which addresses the imbalance causing anginal pain. Other interventions like nitroglycerin or ECG are important but follow after initial rest.

## 심화 해설

Clinical Reasoning and Priority Setting

The scenario describes a client with known stable angina who develops chest pain during exertion. The immediate priority is to decrease myocardial oxygen demand. The 2025 Korean Guidelines for Cardiopulmonary Resuscitation emphasize that for chest pain suggestive of myocardial ischemia, the core first aid principle is to have the person stop all activity and rest immediately to reduce the workload on the heart [1]. This non-pharmacological intervention is the safest and fastest action the nurse can initiate independently before proceeding to further assessments or medication administration.

Instructing the client to sit down and rest addresses the underlying pathophysiology of stable angina: an imbalance between myocardial oxygen supply and demand, typically triggered by physical exertion. By halting activity, the heart rate and blood pressure decrease, thereby lowering myocardial oxygen consumption and potentially resolving the ischemic episode without any medication. While administering sublingual nitroglycerin (option 1) is a standard treatment, current evidence-based protocols for acute chest pain management stress that optimizing the nursing care process begins with immediate positioning and rest, followed by a rapid, systematic assessment . Checking vital signs and oxygen saturation (option 3) is critical but should occur concurrently with or immediately after ensuring the client has ceased the exertional activity that precipitated the pain. Reviewing the medication history (option 2) is an important secondary step to identify potential contraindications or recent changes but does not address the immediate physiological stressor.

The systematic review on coronary heart disease highlights that physiological stressors, including uncontrolled symptoms like acute chest pain, can significantly impact patient outcomes and are often linked to secondary issues such as insomnia, underscoring the importance of prompt symptom control . In the hierarchy of nursing interventions for a symptomatic client, measures that directly mitigate the cause of the symptom—in this case, activity-induced increased oxygen demand—take precedence. Therefore, the first nursing action is to instruct the client to sit down and rest, which immediately begins to correct the supply-demand mismatch and provides a safe baseline from which to continue the assessment and treatment sequence.References (research sources)

- [1]2025 Korean Guidelines for Cardiopulmonary Resuscitation: Part 11. First aid.GuidelineWoo SH, Lee CH, Kim MY, Kim Y, Park CJ, Lee ML, Lee T, Jang K, Jung JH, Ji HK, Chung SP, Kim DK, Kim TY, Sohn Y, Shim G, Jung YH, Oh Y, Youn CS, Lee MJ, Lee J, Jang Y, Jang YS, Cho GC, Cha KC, Heo JS, Hwang SO. (2026) · DOI: 10.15441/ceem.26.076

## 임상 시나리오

Stable Angina: First Response to Exertional Chest PainImmediate Non-Pharmacological Priority
For a client with known stable angina reporting chest pain during ambulation, the highest priority nursing intervention is to instruct the client to sit down and rest immediately. This directly reduces myocardial oxygen demand by decreasing heart rate and blood pressure.

Rest is the safest, fastest, and most independent action a nurse can take. It addresses the underlying pathophysiology of demand ischemia before proceeding to assessment or medication administration.

CautionDo not delay rest to administer sublingual nitroglycerin or obtain vital signs. While these are standard, the immediate goal is to halt the exertional trigger. Assess the patient concurrently or immediately after they stop activity.

## 핵심 개념

- **Stable Angina** — Chest pain or discomfort that occurs predictably with exertion or stress and is relieved by rest or nitroglycerin, caused by fixed coronary artery narrowing.
- **Myocardial Oxygen Demand** — The amount of oxygen the heart muscle requires to function; increased by factors like heart rate, contractility, and wall tension.
- **Sublingual Nitroglycerin** — A vasodilator administered under the tongue for rapid absorption to treat acute angina by reducing preload and coronary vasodilation.
- **Priority Setting in Nursing** — The process of ranking patient problems and interventions by urgency, often using frameworks like ABCs or safety first.
- **Exertional Ischemia** — Inadequate oxygen supply to the heart muscle relative to its demand, typically triggered by physical activity in patients with coronary artery disease.

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