The nurse is caring for a client with a history of coronary artery disease who reports waking up with a sudden onset of viselike chest pressure. The client reports that the pain decreases at rest but continues to feel a constant mid-chest pressure. After obtaining the client's vital signs, which action should the nurse take next?
Explanation & Rationale
A. Listening for extra heart sounds, murmurs, and rhythm is important, but obtaining an ECG and starting continuous monitoring should be prioritized to assess for possible acute coronary syndrome.B. Reducing environmental stimuli is beneficial for patient comfort but is not the immediate priority in assessing and managing potential cardiac events.C. Obtaining a 12-lead electrocardiogram and beginning continuous cardiac monitoring are critical actions to diagnose and monitor for myocardial infarction or other cardiac events. These steps provide vital information for immediate treatment decisions.D. Restricting family and visitors may be necessary but is not the immediate next action compared to performing an ECG and continuous monitoring to assess the client's cardiac status.