After a client is connected to a heart monitor in the emergency room, the nurse notes an elevated ST segment on the ECG strip. What nursing action would have the highest priority for this client?
A)Assess the vital signs and the degree and location of any chest pain.
B)Administer a stat dose of sublingual nitroglycerine spray to dilate the coronary arteries.
C)Notify the physician of the client's dire condition.
D)Place the client in the prone position to reduce the workload of the heart.

Question

Quizplus · Accepted Answer

An elevated ST segment on an ECG strip may indicate myocardial ischemia or infarction, which can lead to severe cardiac complications. Therefore, the nurse should assess the client's vital signs and degree and location of any chest pain as the highest priority. This information can help determine the severity of the condition and guide further interventions. Administering nitroglycerine or placing the client in the prone position should only be done after assessing the client's condition and with physician orders. Notifying the physician is important, but it should not be the first action taken without first assessing the client.

After a Client Is Connected to a Heart Monitor in the Emergency