NCLEX style question I'm confused about

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Hi everyone, I have a question on a NCLEX practice question that I just do not understand why the answer is what it is. Here's the question...

A nurse admits a client transferred from the emergency room. The client, diagnosed with a myocardial infarction, is complaining of substernal chest pain, diaphoresis and nausea. The first action by the nurse should be

1. Order an EKG

2. Administer morphine sulphate

3. Start an IV

4. Measure vital signs

According to the NCLEX review the answer is 2.

We can assume that an EKG was done in the ER and that an IV was started. And I agree that pain should be addressed right away, however, from all my teaching at school, Morphine (or any other opioid) should never be given without assessing the respiratory rate (and that it's good to have a BP, but that respiratory rate was a MUST have). If I gave morphine in clinical without assessing the RR, I'd get written up.

Does anyone know why the answer would be 2. I'm concerned that when I go to take the NCLEX, I'll have problems with the disparity between what I was taught and what they want. Help! :)

Thanks for your opinions on this!

Cassi

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We learned the acronym MONA for treatment of a myocardial infarction/chest pain - Morphine, oxygen, nitrate, aspirin - and that's the order in which it is to be given. I know that pain is a BIG issue with an MI...maybe because pain increases anxiety and worsens the problem...?

I'll have to go back and review my notes from last semester. We're going to be on a cardiac floor this summer for our FINAL semester (!!) so it will probably be handy to know.

Good luck with NCLEX! Sarah

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There are 2 reasons I could think of answer 2 as being correct.

First, the MONA response as morphine would be given for the pain.

Second, the patient was in ER first which means the EKG was done, the IV started, and vitals would have been taken before the patient was brought to you so you should have a fairly recent set of vitals. Although, the Morphine should have been given in the ER before the transfer to the unit.

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The main thing they've drilled into our heads at my school is that pain can kill. So controlling the MI patient's pain would help stabilize their vitals.

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Think Maslow when looking for the answer they want :)

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Specializes in Utilization Management.

Aha, but Morphine is given for MORE than the control of the pain in an MI. Morphine has another benefit--it actually improves the action of the heart by decreasing preload. Its vasodilator effect can also cause hypotension, an effect can also be a benefit in an AMI.

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Specializes in RN, BSN, CHDN.

I believe you have to deal with the pain first as that is the priority in the question.

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I would have guessed 4. But it probably is 2, b/c they would bring him up with a recent set of vitals.

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Specializes in Critical Care/ICU.

Pain also = tissue damage, you want to stop that immediately. Like Angie O said, opening up the vasculature (vasodilation) with morphine decreases the workload on the heart thereby decreasing oxygen requirements and comsumption of the heart. Heart doesn't work as hard; oxygen is used more efficiently.

Here's where you use your critical thinking - If the patient's in pain and talking to you, you can pretty much count on an adequate respiratory rate.

Be sure to take the entire situation into account. Not just step-wise things.

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Thanks, everyone. We haven't gotten to heart problems yet...other than real general. I believe it's next semester when we do pathophys. I want to thank you all for being nice in your responses to me and not treating me like I'm stupid. The email list I got this question from has a few people who really acted like I was stupid...even though the total number of people who would have guessed the same as I would have was 14 and the total number who guessed the correct answer was 18....obviously, there are many who struggled with this question.

Anyway, thanks again. I have one more year and 7 weeks left before I'm done with nursing school...so I know I have a lot to learn still.

Cassi :)

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I agree with angioplasty....the morphine is not just given for pain it is given to decrease sympathetic stress and increase myocardial oxygenation...as for maslow, pain is considered a psychosocial need not physiological (atleast for nclex purposes). Good luck in your schooling!! It sounds like you'll make a great nurse!

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Specializes in CV Surgery Step-down.

Ohhh... I liked that question!

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