A client presents to the emergency department with sudden onset of severe, crushing chest pain radiating to the left arm, diaphoresis, and nausea. The electrocardiogram (ECG) shows ST-segment elevation in leads II, III, and aVF. Which of the following is the priority nursing action?
- APrepare the client for immediate cardiac catheterization.
- BAdminister aspirin 325 mg orally.
- CAdminister sublingual nitroglycerin 0.4 mg.
- DObtain a complete medical history from the client.
Show answer & explanationAnswer & explanation
Correct answer: A. Prepare the client for immediate cardiac catheterization.
The client's symptoms and ECG findings (ST-segment elevation in leads II, III, and aVF, indicating an inferior wall myocardial infarction) point to an acute myocardial infarction (STEMI). The priority for STEMI is rapid reperfusion therapy, with immediate cardiac catheterization (PCI) being the gold standard to restore blood flow to the ischemic myocardium and minimize cardiac damage. While aspirin and nitroglycerin are important interventions, preparing for immediate reperfusion takes precedence in this time-sensitive emergency.
Why the other options are wrong
- B. Aspirin is crucial but not the absolute first priority over preparing for definitive reperfusion.
- C. Nitroglycerin helps with pain and vasodilation but does not address the underlying occlusion as definitively as reperfusion therapy in STEMI.
- D. A medical history is important, but not the priority when the client is experiencing an acute, life-threatening event requiring immediate intervention.
Acute Myocardial Infarction (AMI) - STEMI
A severe form of heart attack characterized by persistent ST-segment elevation on ECG, indicating complete occlusion of a coronary artery and transmural ischemia.
- Caused by prolonged ischemia leading to myocardial cell death.
- ECG shows ST-segment elevation in at least two contiguous leads.
- Priority treatment is immediate reperfusion (PCI or fibrinolysis) to restore blood flow.
Memory trick: STAT My Heart, Get That Artery Open!