Priority NCLEX Situation Assistance?

[belljar1995, PhD, RN]

HI everyone, I hope that this is not splitting hairs so to speak, but I was wondering about the difference between "priority" and "first action". Is there a difference? As I've been studying for NCLEX, I've come up against two scenarios and I'm wondering if I'm thinking them through:

1) ER and Acute MI--what is your PRIORITY action? --among the two most reasonable answers are: 1) administer 02 and 2) give Nitro. I feel like my PRIORITY is to give the nitro, since alot of the research seems to say that unless the 02 sat is below 94%, 02 doesn't impact outcomes--whereas nitro does. HOWEVER, in my answer key 02 is the correct answer. So, my question is...Can a nurse administer nitro w/o a doctor's order? is this why 02 is the priority action? Am I missing something?

2) Inpatient client complains of "fullness" in the chest--no other symptoms. What is your FIRST action? The two reasonable answers are 1) do an EKG and 2) Call physician. Apparently the answer is "call physician". Can a nurse order an ekg?

3) Is there a real difference between "first" and "priority" action? Or are these essentially the same thing? We were told in school they technically are the same thing, but are they really??

I think I'm a bit confused because I'm in an accelerated NP (direct entry for people with BS in another field) so we become eligible for nclex after we are 2/3 finished with the NP program--and I'm wondering if the NP training is affecting my thinking process on the nclex ?

If anyone can shed some light, I'd appreciate it :)

[Rose_Queen, BSN, MSN, RN]

Doctor's orders are required for pretty much any medication given or test performed. However, there may be standing orders and protocols that are started when a patient meets certain criteria. This is why nitro and many other meds/interventions can be given/done by paramedics prehospital and why nurses can do things such as give nitro and obtain an EKG prior to an ER physician laying eyes on a patient.

Does whatever source you're using provide rationales?

[203bravo, MSN, APRN]

think about it a little differently -

1. during an MI the "pain" or "tightness" felt by the patient is the cardiac muscle being deprived of oxygen and thus starting to die. Here you don't worry as much about the SpO2 since your first goal is to get more oxygenated blood to the heart. If you then apply the ABC's (A) is the airway patent? probably so if the patient is talking to you.. (B) provide O2 to help increase the oxygen level in the blood and © provide nitrates.. ntg.. to dilate the vessels and get more blood to the heart muscle. We learn MONA, but remember that the correct order is always O2, ntg, asa, mso4.

2. if the patient started c/o a "crushing" or "fullness" type chest pain and you suspect a cardiac event what should you do first? What would help the patient the fastest? Call the DR! think about how ordering an EKG would help the patient? it wouldn't,, may help the DR once they arrive on the unit (and one of the DR 1st orders while on the phone will probably be order the EKG and have it ready upon arrival) but prior to alerting the DR the EKG cannot help the nurse care for the patient at all... the nurse cannot diagnosis the EKG and make any decisions about treatments or decide if the DR is to be called or not based on the EKG.. so again it is of no help to the patient as the first consideration.

Best of luck.

[belljar1995, PhD, RN]

Thank you both! This is really helpful. The rationale wasn't *really* given in the book--you both explained it MUCH better. I think I'm also just in panic mode and starting to confuse everything--I just want this exam over :)

Thanks again for the help--MUCH appreciated!