Apply the clinical judgement/cognitive skill, prioritize hypotheses. According to Maslow’s Hierarchy of needs theory, physiological needs are the priority, followed by safety, and psychosocial needs.
a) Call the client’s family
Although this may seem like an important nursing action when the client is experiencing an MI, the question is asking what the priority orders are for the nurse to conduct, there are other options in the answers that will first address the client’s physiological needs. Once these are implemented, then the nurse can call the client's family to meet psychosocial needs.
b) Administer 2.5 mg Morphine Sulfate IV
The client rated their pain at a 9/10 upon initial assessment, further delay of pain management can lead to increased anxiety in the client and increased oxygen demand by the heart muscles. Since this is a SATA question, this should be included in your priority nursing care to adequately address the client’s physiological needs. Administration of opioid analgesics such as morphine sulfate are a priority in pain management of the client with an MI as other pain relief measures such as nitroglycerin may not be effective after the initial dose.
c) Insert an indwelling urethral catheter
There is no indication in the nursing notes that would indicate the need for the nurse to insert an indwelling urethral catheter at this point in time.
d) Obtain blood specimen for laboratory tests: complete blood count (CBC), electrolytes, creatine-kinase myoglobin (CK-MB), troponin, myoglobin, and total CK
In order for the health care provider (HCP) to diagnose an MI and determine the best treatment option for this client, diagnostics such as laboratory tests must be obtained by the nurse. Within the CBC the white blood cell (WBC) count is elevated the day after an MI and can remain elevated for 1 week. Troponin level rises within 3 hours and can remain elevated for 7-10 days. CK-MB elevation occurs 18 hours after chest pain begins, and returns to baseline 48 to 72 hours afterwards. Myoglobin levels rise within 2 hours after myocardial ischemia with rapid decline after 7 hours. Total CK levels rise in 6 hours after chest pain begins, and has a peak of 18 hours after myocardial ischemia.
e) Administer another nitroglycerin tablet sublingually
You may think another BP measurement must be obtained before administering another nitroglycerin tablet. However, there is no data provided in the nurse’s notes that the BP is abnormal and the client is still experiencing 9/10 chest pain. Remember, the nurse would administer 3 nitroglycerin tablets 5 minutes apart from each other to relieve chest pain in a hospitalized client.
