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What is the priority action for a nurse when a patient reports chest pain?
Asked on Feb 09, 2026
Answer
When a patient reports chest pain, the priority action for a nurse is to assess the patient's vital signs and initiate a focused cardiovascular assessment to determine the severity and potential cause of the pain. This is crucial for identifying any life-threatening conditions such as myocardial infarction.
Example Nursing Steps:
- Step 1 – Assess the patient's vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation.
- Step 2 – Administer oxygen if needed, ensure the patient is in a comfortable position, and prepare for potential administration of medications like nitroglycerin.
- Step 3 – Monitor the patient's response, document findings, and communicate with the healthcare provider for further evaluation and orders.
Additional Comment:
- Assessing chest pain involves checking for associated symptoms such as shortness of breath, diaphoresis, and nausea.
- Prioritize interventions based on the ABCs (Airway, Breathing, Circulation) and pain severity.
- Consider potential causes of chest pain, including cardiac and non-cardiac origins.
- Ensure timely communication with the healthcare team to facilitate prompt treatment.
- Documentation should include the patient's description of the pain, assessment findings, interventions, and the patient's response.
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