Common Priority Interventions

A 64-year-old male patient is admitted to the emergency department with complaints of chest pain radiating to his left arm and jaw. He is diaphoretic and slightly short of breath. His vital signs are as follows:

• BP: 168/92 mmHg
• HR: 112 bpm
• RR: 24 breaths per minute
• O2 Sat: 92% on room air
• Temperature: 98.7°F (37°C)

An 12-lead ECG reveals ST-segment elevation in leads II, III, and aVF, indicating an acute inferior myocardial infarction. The patient has no known drug allergies and no prior medical history of anticoagulant use.

Which interventions should the nurse implement immediately? Select 5 potential interventions.

A 58-year-old female is admitted to the emergency department with complaints of crushing chest pain, shortness of breath, and nausea that started 45 minutes ago. She has a history of hypertension and Type 2 diabetes. Her vital signs are as follows:

• BP: 160/88 mmHg
• HR: 118 bpm
• RR: 26 breaths per minute
• O2 Sat: 94% on room air
• Temperature: 99.1°F (37.3°C)

The ECG shows ST elevation in the anterior leads (V1-V4), and the patient is diagnosed with an acute anterior wall myocardial infarction.

Based on the scenario, select the appropriate nursing actions for each situation in the matrix below:

Type an “X”

Fill in the blank with the most appropriate action based on the patient’s condition.

Scenario:
A 55-year-old male with a history of coronary artery disease presents with severe chest pain, nausea, and diaphoresis. His ECG shows ST-segment elevation in leads II, III, and aVF. He is diagnosed with an inferior wall myocardial infarction. The nurse immediately administers _______________ to prevent further clot formation in the coronary arteries.

A 22-year-old male presents to the emergency department with complaints of severe abdominal pain that started in the periumbilical region and has since migrated to the right lower quadrant. He rates the pain as 8/10 and describes it as sharp and constant. He is also experiencing nausea and has not had a bowel movement in 24 hours. His vital signs are:

• BP: 138/84 mmHg
• HR: 100 bpm
• RR: 22 breaths per minute
• Temperature: 101.3°F (38.5°C)

On examination, the patient has guarding and rebound tenderness in the right lower quadrant, consistent with acute appendicitis. The healthcare provider has confirmed the need for an appendectomy.

Which of the following nursing interventions should be the priority for this patient? (Select one.)

A 35-year-old female with a history of hyperthyroidism presents to the emergency department with agitation, tremors, severe anxiety, and palpitations. She also complains of nausea, vomiting, and diarrhea. On assessment, she is tachycardic with a heart rate of 150 bpm, febrile with a temperature of 104.1°F (40.1°C), and hypertensive with a BP of 160/90 mmHg. The healthcare provider suspects a thyroid storm.

Which of the following actions should the nurse perform as the priority for this patient? (Select one.)

A 30-year-old woman at 36 weeks gestation is admitted to the labor and delivery unit with complaints of a severe headache, visual disturbances (seeing spots), and epigastric pain. Her blood pressure is 170/110 mmHg, and she has +3 proteinuria. Shortly after admission, the patient begins to have tonic-clonic seizures. The healthcare provider diagnoses her with eclampsia.

Which of the following actions should the nurse perform as the priority for this patient? (Select one.)

A 45-year-old male is admitted to the ICU after a motor vehicle accident with a traumatic brain injury. He is intubated and sedated. The nurse observes that the patient has become increasingly restless, his pupils are unequal, and his blood pressure is 160/95 mmHg with a heart rate of 48 bpm and irregular respirations. The healthcare provider suspects increased intracranial pressure (ICP).

Which of the following actions should the nurse perform as the priority for this patient? (Select one.)