A 69-year old male patient presents to emergency department with complaints of mid-sternal chest pain. Which of the following nursing actions should take priority?
  1. A complete history with special concern about similar symptoms in the past
  2. Record electrocardiogram
  3. Careful assessment of vital signs
  4. Cardiac and chest auscultation
Explanation
Answer- C - The priority nursing action for a patient presenting to emergency in distress is always assessment of vital signs. This helps to know the extent of physical compromise and provides background information to plan further assessment and treatment. A complete medical history is definitely important; this should include onset of symptoms as well as history of similar complaints in the past. Recording an electrocardiogram is also important, but these are not the first priority. Similarly, cardiac and chest examination and auscultation may elicit useful information after vital signs are assessed.
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