Medical Surgical Critical Care Cardiac Critical Care #3

Question

A client arrives in the emergency department with chest pain #7 out of #10 on the pain scale; a troponin level of 0.01 ng/ml on the first lab draw. When placed on the ECG monitor reveals the following rhythm:

Which is the priority intervention by the nurse?

Answers

  1. Continue to monitor the client for a heart attack since the cardiac rhythm and troponin level is abnormal.
    • Rationale:

      This answer is not correct because although the client should continue to be monitored, the client’s cardiac rhythm is normal sinus rhythm and the troponin level is low at 0.04 ng/ml.

  2. Continue to assess the client on the cardiac monitor, but ask the health care provider to check other options since the cardiac rhythm is normal sinus rhythm and the troponin level is low.
    • Rationale:

      This answer is correct because the nurse should continue to assess the client on the cardiac monitor, but ask the health care provider to check other options since the cardiac rhythm is normal sinus rhythm and the troponin level is low. Many client’s who come to the emergency room have chest pain that is not related to the heart.

  3. Rush the client to the cardiac catheter lab to be catheterized since both the rhythm and troponin levels are abnormal.
    • Rationale:

      This answer is not correct because the client should not be rushed to the cardiac catheter lab to be catheterized since both the troponin and ECG monitor are normal.

  4. Administer nitroglycerin 0.4 mg SL every 5 minutes X 3 and if no relief, give Morphine 2 mg IVP as ordered.
    • Rationale:

      This answer is not correct because although administration of nitroglycerin 0.4 mg SL every 5 minutes X 3 is the standard for chest pain, and if no relief Morphine 2 mg IVP may be ordered, the emergency medical team probably tried these interventions in the ambulance ride over to the hospital. Since the ECG is normal and troponin level is low, the health care provider should try other options of alleviating the pain.

Overview

When a client comes to the emergency department with chest pain of #7 out of #10 on the pain scale, it is important that the client be placed on the ECG monitor and labwork be drawn to rule out a heart attack. Troponin is one of the cardiac proteins released by the heart when the muscle is damaged or with a heart attack. The higher the troponin level, the greater the heart damage. The normal troponin level is between 0 and 0.4 ng/ml.

Explanation

Learning Outcomes

When a client comes to the emergency department with chest pain of #7 out of #10 on the pain scale, it is important that the client be placed on the ECG monitor and labwork be drawn to rule out a heart attack. Since the ECG monitor reveals normal sinus rhythm and the first troponin level is low at 0.04 ng/ml, the nurse should continue to assess the client on the cardiac monitor, but ask the health care provider to check other options, such as esophagus, gastroesophageal reflux disease, gallbladder problems, anxiety, stress, or depression.

Test Taking Tip

Know normal sinus rhythm on the cardiac monitor and the normal troponin levels.

Video Rationale