NCLEX Practice Test

Which interventions should the nurse complete for a client who comes to the emergency department with crushing substernal chest pain? Select all that apply.

1. Administer morphine

2. Check blood pressure and heart rate

3. Draw blood specimen

4. Obtain a 12-lead ECG

5. Position client in the supine position

The correct answer is: Administer morphine

Administering morphine is indeed an appropriate intervention for a client experiencing crushing substernal chest pain, as it helps alleviate pain and can also reduce the workload on the heart. In the context of this situation, morphine is commonly used for managing acute coronary syndrome (ACS) because it provides both analgesic and vasodilatory effects, which can be beneficial for someone potentially experiencing a heart attack. Checking blood pressure and heart rate is also critical in this scenario, as it provides essential information about the client's hemodynamic status and heart function, which aids in assessing the severity of the condition and guiding further interventions. Drawing blood specimens is necessary for diagnostic purposes, including checking cardiac biomarkers like troponin levels, which are important in diagnosing myocardial infarction. Obtaining a 12-lead ECG is crucial in emergency situations involving chest pain, as it helps identify the presence of ischemia, infarction, or arrhythmias, providing essential information for appropriate management. Positioning the client in a supine position is generally not recommended for individuals with acute chest pain. Often, a position of comfort, such as sitting up, may be more appropriate to ease respiratory distress and promote circulation. In summary, while administering morphine is a correct response in managing