A nurse on a medical-surgical unit is caring for a client who reports pain in the jaw, back, and shoulder, shortness of breath, and nausea.
Which of the following actions should the nurse take?

Choice A - Indicated:

• Administering oxygen to maintain oxygen saturation >94% is recommended in suspected acute coronary syndrome (ACS) to prevent myocardial hypoxia.
• Oxygen therapy is not routinely given if SpO₂ is ≥94%, but if there are signs of hypoxia, respiratory distress, or low saturation, it is appropriate.

Choice B - Contraindicated:

• Intubation is not indicated unless the patient has severe respiratory distress or impending respiratory failure.
• This client is not in respiratory failure (no severe dyspnea, altered consciousness, or worsening hypoxia).

Choice C - Indicated:

• Continuous ECG monitoring is essential in suspected ACS to detect arrhythmias, ischemia, and ST changes.
• ECG findings will guide early intervention, including medication administration (e.g., aspirin, nitroglycerin) or reperfusion therapy.

Choice D - Nonessential:

• Family history of cardiovascular disease is important for risk assessment but is not a priority in an acute setting.
• While it can help with long-term management, immediate interventions (oxygen, ECG, medications) take precedence.

Rationale for correct answers:

• Gastroesophageal reflux disease (GERD): GERD is a condition where stomach acid frequently flows back into the tube connecting the mouth and stomach (esophagus). This backwash (acid reflux) can irritate the lining of the esophagus and lead to symptoms such as heartburn and pain between the shoulder blades. The client’s report of pain between the shoulder blades and history of hypertension aligns with GERD symptoms.
• Severe pain between shoulder blades and history of hypertension: These symptoms indicate the possibility of GERD. The client's pain is exacerbated by activity, which is a common characteristic of reflux pain. Also, a history of hypertension increases the likelihood of GERD due to its association with increased abdominal pressure.

Rationale for incorrect answers (Response 1 Options):

• Myocardial infarction: A myocardial infarction (heart attack) would typically present with elevated troponin levels and possibly ST-segment elevation on ECG. The client’s troponin levels are within normal limits (normal troponin I levels are typically less than 0.04 ng/mL) and ECG shows no ST-segment elevation, making this diagnosis less likely.
• Aortic dissection: This condition would usually present with severe, sudden chest pain that radiates to the back, and it is a medical emergency. The client's presentation does not fit the acute, severe pain typically associated with aortic dissection, and there is no mention of sudden onset or ripping/tearing sensation.
• Musculoskeletal strain: This condition would likely be characterized by localized tenderness and pain with movement. The client denies radiation of pain, and the pain is exacerbated by activity, which can overlap with GERD rather than musculoskeletal strain.

Rationale for incorrect answers (Response 2 Options):

• Elevated troponin levels and ST-segment elevation on ECG: These findings are indicative of myocardial infarction. The client’s troponin levels are within normal limits, and the ECG shows sinus rhythm with no ST-segment elevation, making myocardial infarction unlikely.
• Heartburn and regurgitation after meals: While these are classic symptoms of GERD, the client's primary complaint is severe pain between the shoulder blades. The absence of these specific symptoms in the client’s report does not support this option as the primary evidence.
• Localized tenderness and pain with movement: These symptoms are more characteristic of a musculoskeletal strain. The client's pain does not exhibit localized tenderness, and although it is activity-related, it lacks the hallmark features of a musculoskeletal strain.