Question

A nurse in the ER is caring for a patient who reports chest pain of 8 out of 10. Which of the following action should the nurse take first?

A. Obtain cardiac enzymes and biomarkers
B. Administer morphine
C. Transfer to ICU
d. Prepare patient for cardiac Cath

Answer 1

The nurse's first action in response to a patient presenting with intense chest pain should be to assess the patient's vital signs and perform an ECG to rule out cardiac issues.

Step-by-step explanation:

When a patient in the ER reports intense chest pain, such as an 8 out of 10 on the pain scale, the first action a nurse should take is to assess the patient's vital signs and perform an electrocardiogram (ECG), if it is within the nurse's scope of practice and availability of the equipment. This initial step is important to determine if the chest pain is cardiac-related, which can be a sign of acute coronary syndrome or myocardial infarction. Obtaining vital signs provides crucial information about the patient's hemodynamic status, and the ECG can show if there is ischemia or other cardiac abnormalities. Often, teams follow specific protocols such as the Advanced Cardiac Life Support (ACLS) guidelines which also provide a structured approach for treating such emergencies. Thus, the options provided like administering morphine, obtaining cardiac enzymes, transferring the patient to the ICU, or preparing for a cardiac catheterization would follow based on the initial assessment and diagnostic findings.