# An RN is assigned 4 clients on a medical-surgical unit with an LPN and an assistive personnel (AP). At 0830 a 61-year-old client admitted 2 days ago for cellulitis, with type 2 diabetes and hypertension, reports chest pressure that began 10 minutes ago while sitting in bed and spreads to the jaw. The pressure has continued while at rest. The client finished breakfast 30 minutes earlier. The client is diaphoretic; blood pressure is 158/94 mm Hg, heart rate 104/min, respiratory rate 20/min, and oxygen saturation 96% on room air. The client has no aspirin allergy or active bleeding, and unit standing orders for chest pain are in place. The other 3 clients are stable. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=617421&lang=en > language: en > subject: Establishing Priorities > category: MOC ## Question An RN is assigned 4 clients on a medical-surgical unit with an LPN and an assistive personnel (AP). At 0830 a 61-year-old client admitted 2 days ago for cellulitis, with type 2 diabetes and hypertension, reports chest pressure that began 10 minutes ago while sitting in bed and spreads to the jaw. The pressure has continued while at rest. The client finished breakfast 30 minutes earlier. The client is diaphoretic; blood pressure is 158/94 mm Hg, heart rate 104/min, respiratory rate 20/min, and oxygen saturation 96% on room air. The client has no aspirin allergy or active bleeding, and unit standing orders for chest pain are in place. The other 3 clients are stable. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. Condition Select 1 Gastroesophageal reflux after a meal Acute coronary syndrome Pulmonary embolism Stable angina pectoris Actions to take Select 2 Give the prescribed PRN antacid and reassess Assess the client now and obtain a 12-lead ECG Have the LPN assess while the RN calls the provider Give chewable aspirin per the standing order Request a stat CT pulmonary angiogram Parameters to monitor Select 2 ST segments on 12-lead ECG Serial D-dimer levels Serial serum lipase levels Serial troponin levels Arterial PaO2 on blood gas ## Explanation Chest pressure at rest that spreads to the jaw, with diaphoresis and tachycardia in a client with diabetes and hypertension, is acute coronary syndrome until proven otherwise. The RN assesses the client personally, obtains a 12-lead ECG, and gives aspirin under the standing order. Serial troponin levels and ST segments show whether myocardial injury is evolving. ## In-depth explanation Quick answer Acute coronary syndrome. The RN assesses the client now with a 12-lead ECG and gives chewable aspirin per the standing order. Monitor serial troponin levels and ST segments on the 12-lead ECG. Why this is correct Pressure that spreads to the jaw, diaphoresis, tachycardia, and risk factors (diabetes, hypertension) support ACS. Stable angina is brought on by exertion and eases within a few minutes of rest; this pressure began at rest and has lasted 10 minutes, the pattern of an acute coronary syndrome. A 12-lead ECG within 10 minutes and aspirin are first steps, and a new, unstable change requires RN assessment and judgment, which cannot be delegated. Troponin trends and ST segments show whether myocardial injury is evolving. Easy analogy or mental picture The RN is the air-traffic controller: routine flights can be handed to others, but the plane in trouble gets the controller's full attention. Memory hook Unstable = RN eyes on. ECG in 10, aspirin chewed. NCLEX decision rule Delegate stable, predictable tasks; keep assessment, evaluation, and judgment for any client whose condition is new or unstable. Why the other choices are wrong An antacid is tempting because the client just ate, but reflux does not explain diaphoresis and tachycardia, and treating it first delays ACS care; lipase follows pancreatitis, another upper-abdominal cause, not this picture. Pulmonary embolism is a concern in a hospitalized client, but oxygen saturation is 96% and respiratory rate 20/min, and the pain is pressure radiating to the jaw, so a CT angiogram, D-dimer, and PaO2 follow the wrong condition. Stable angina starts with exertion and resolves with rest; this pain started at rest. Having the LPN assess while the RN calls the provider hands off the assessment of an unstable client, which stays with the RN; the RN calls the provider with the assessment and ECG findings. References 1American Heart Association — Warning Signs of a Heart AttackChest pressure radiating to the jaw with sweating as warning signs 2MedlinePlus — Heart AttackInitial evaluation with ECG, troponin, and aspirin 32026 NCLEX-RN Test Plan (NCSBN)Delegation and prioritization within Management of Care ## Clinical scenario Scenario During a shift with an LPN and AP, a client with diabetes develops chest pressure at rest that spreads to the jaw, with diaphoresis and tachycardia, 30 minutes after breakfast. ## Key concepts - **Acute coronary syndrome** — A spectrum of acute myocardial ischemia that includes unstable angina, NSTEMI, and STEMI. - **Delegation** — Transferring a task to a competent person while the RN keeps accountability; assessment of unstable clients is not delegated. - **Troponin** — A cardiac protein released into the blood when heart muscle is injured. ## Related questions - [A nurse in a busy emergency department is triaging five clients who arrive simultaneously.…](https://mymerci.kr/pages/nclex_q.php?qn_id=368320&lang=en) - [At shift change, a charge nurse receives six postoperative reports. 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