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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

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My "don't read into the questions" thinking led me to towards "brief assessment" because the nurse can do this immediately without an order and brief assessment could be as simple as observing the patient grimacing in pain and clutching chest. On the other hand, with the nitro answer, I had to stop and ask myself "does the nurse have an order for this?" "has the nurse even seen the patient at all up to this point?"

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Hope the OP got through the NCLEX in spite of this question.

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