Final answer:
The priority action for a nurse triaging a client with chest pain is to perform an Electrocardiogram (ECG). This diagnostic test is vital for identifying potential cardiac events, such as myocardial infarction or angina pectoris, and guides further management decisions. Other measures, although important, should follow the initial ECG assessment. The multiple-choice option is (c) Perform Electrocardiogram (ECG).
Step-by-step explanation:
Priority Action for Chest Pain in Ambulatory Care Setting
When triaging a client presenting with chest pain in an ambulatory care setting, the nurse's priority action should be to perform an Electrocardiogram (ECG). This non-invasive test is critical for assessing the heart's electrical activity and can help in identifying any abnormalities that may be indicative of an acute myocardial infarction (MI) or angina pectoris. Due to the potential severity of chest pain which could be suggestive of a cardiac event, such as an MI, obtaining an ECG promptly can be lifesaving. While actions such as administering ASA (aspirin) may also be important, performing an ECG is essential in the early stages of triage for someone with chest pain to guide further management decisions.
John, a 65-year-old man with asthma and type 2 diabetes, presented with symptoms including headache, chest pain, coughing, shortness of breath, fever, and gastrointestinal upset. Given that chest pain can be a symptom of ischemia and other serious cardiac conditions, the nurse should prioritize diagnostic assessments like ECG over full head-to-toe assessments, administering medications, or immediately calling emergency services, unless the patient's condition suggests a need for immediate advanced life support.
Chest pain can have various causes, including angina and acute MI, both involving the lack of blood flow and oxygen to the heart muscles. It is crucial to assess the presence of complementary symptoms such as difficulty breathing, irregular heartbeat, nausea, and sweating. These additional symptoms can help differentiate the cause of chest pain and guide the appropriate intervention.
The multiple-choice option is (c) Perform Electrocardiogram (ECG).