Stumped on a priority question

Hi everyone,

I have quick question that arose while studying for NCLEX. If a patient comes to the ER with left anterior chest pain, poss. unstable angina or MI what nursing action do you take first? auscultate breath sounds, administer nitro, insert IV cath, or obtain a brief patient health hx.

I went with obtain a patient history to determine if the patient had taken nitro x3 at home before being admitted, so you dont OD the patient on nitro. Apparently the answer is administer nitro first...is nitro OD not an issue with possible MI?? Thanks

According to my instructor, OD is not an issue with nitro. She says the only reason there's a three-dose limit is because you don't want someone with chest pains taking dose after dose before they finally pick up the phone and call an ambulance.

Of the choices you listed as possible answers, nitro is also the only one that's part of the "OMAN" protocol for chest pain emergency:

oxygen

monitor

aspirin

nitro

Your question is an example of how NCLEX style questions are absolutely useless. In the real world, you'd be doing all four answers at roughly the same time.

Analyzing the question, administer nitro stands out as the right answer because nitroglycerin vasodilates the coronary arteries, thus increasing bloodflow to the potentially compromised area of the heart, and less importantly, perhaps relieving the associated anginal pain. Time is muscle and nitro along with oxygen, aspirin, and pain relief are the first line medicinal treatments for an acute MI.

Back to "time is muscle", none of the other alternatives are interventions. This is perhaps the key word of your problem. While obtaining health history is indeed important, you aren't nearly as concerned about a "nitro overdose" as you are about the potential acute MI. In fact, to the best of my knowledge the only problem with too much nitro is low blood pressure. All nitrates have incredibly short halflifes of just a couple of minutes, so the effects of old nitro will have worn off on the way en route to the hospital unless they have a transdermal patch.

Back to reality, you'd be bringing them SL nitro and an ASA pill while putting them on 2L O2, followed by starting an IV with a rainbow lab draw and likely administering a couple mg of morphine IV. All the while, asking health hx and working in an assessment.

MONA...is what I used but based on your choices: NITRO...I agree with freedom 42, we tell patients to use Nitrox3 so they can actually call EMS and not just keep giving themselves Nitro...

On the other hand, if you had Morphine as a choice, I would pick that due to the fact that it decreases cardiac workload and also alleviates the pain...:)

Yes MONA is what I use, too.:)

Thanks! These darn NCLEX questions are killing me!!!!!!!

Tip for NCLEX - Every option is valid. In other words - this fella came in without taking anything. You assume that unless told otherwise... in their minds.. ok he's having an MI - but you're taking him into the room to assess him while he's dying.

I learned from HURST - ASSUME THE WORST. Don't do anything that puts off treatment. Assessing isnt an intervention - they want you to intervene in that case.

Also - be careful posting that specific of info - NCSBN monitors these boards from what I gather...

MONA...is what I used but based on your choices: NITRO...I agree with freedom 42, we tell patients to use Nitrox3 so they can actually call EMS and not just keep giving themselves Nitro...

On the other hand, if you had Morphine as a choice, I would pick that due to the fact that it decreases cardiac workload and also alleviates the pain...:)

I learned if you're faced with Nitro AND Morphine as options - you pick morphine first. It's the MAIN drug for MI. It's a vasodilator (which Nitro does) as well as it slows you down and reduces the pain.

Hope that helps someone :)

nitro is also the only one that's part of the "OMAN" protocol for chest pain emergency:

oxygen

monitor

aspirin

nitro

Never heard of OMAN - we learned MONA - the only difference is Morphine for "M" instead of Monitor??

Never heard of OMAN - we learned MON, A - the only difference is Morphine for "M" instead of Monitor??

Interesting. We were taught that IV morphine follows aspirin and nitro, respectively, only if the pain has not been relieved.

For what it's worth, we work out of Wagner, John and Kidd's "High Acuity Nursing" text book, 2006 edition, which cites OMAN. Our instructors did acknowledge MONA but said it had been superceded by OMAN -- not sure when.

Interesting. We were taught that IV morphine follows aspirin and nitro, respectively, only if the pain has not been relieved.

Morphine is part of our hospital's core measures for acute MI, because aside from pain relief it has a small vasodilation effect, however, its use is in the air according to studies. Some show an increase in mortality associated with the use of morphine as a first line treatment in patients with chest pain.

Vague question in my book. "Nursing action" does not necessarily mean "intervention"; assessing IS an action, is it not? So we can't argue that the question specifically is asking for an intervention.

Are we to assume that the descriptive info "possible unstable angina or MI" is coming from a someone with medical diagnostic scope of practice? Are we to assume the patient has already been asked about any past adverse reactions to nitro? Are we to assume that if giving nitro is the top priority action of those choices that the nurse has already confirmed that there's an order for it? Are we to assume that since it's an ER there must be a standing order for nitro in that circumstance? Are we to assume that the nurse isn't just walking up to an unfamiliar patient for the first time and giving them nitro solely based upon the sourceless information given? Are we to assume the nurse has already done their own brief nursing assessment and/or witnessed the medical assessment? Are we to assume that the description "left anterior chest pain" means that the patient is still currently experiencing chest pain thus making any "brief assessment" essentially redundant and unncessary in this scenario with these options?

Remeber not to read into the questions. If you hear yourself going "Well, what if"? Stop, because you are about to analysis yourself into the wrong answer.