Given the electrocardiogram tracing below for a client who is unresponsive and without a pulse, what should be the nurse’s priority action?

Choice A rationale
While dizziness after the first dose of captopril can be concerning, it is not uncommon as the body adjusts to the medication. It is important to monitor this patient, but they are not the highest priority.
Choice B rationale
A patient exhibiting new-onset confusion, restlessness, and cool, clammy skin should be prioritized for assessment. These symptoms could indicate a serious condition such as shock or decreased cardiac output. This patient may be experiencing a rapid decline in condition and should be assessed immediately.
Choice C rationale
While a patient on oxygen therapy with bilateral crackles at the lung bases may have worsening heart failure, they are not the highest priority if they are stable. Crackles at the lung bases are a common finding in heart failure and indicate fluid accumulation in the lungs.
Choice D rationale
A patient on IV nesiritide (Natrecor) with a blood pressure reading of 100/62 is not the highest priority. While this blood pressure is on the lower side, it is not critically low.
Nesiritide can cause hypotension, so this patient should be monitored, but they are not the highest priority if they are stable.

Choice A rationale
Administering Lasix (a diuretic) would not be the most immediate intervention for a patient experiencing increased chest pain after taking sublingual nitroglycerin. Lasix is used to treat fluid retention (edema) and swelling caused by congestive heart failure, liver disease, kidney disease, and other medical conditions. It works by causing the kidneys to get rid of unneeded water and salt from the body into the urine.
Choice B rationale
The most important nursing intervention for a patient experiencing increased chest pain after taking sublingual nitroglycerin would be to increase myocardial oxygenation. This can be achieved by administering supplemental oxygen and ensuring the patient is in a position that maximizes respiratory efficiency (such as semi-Fowler’s position). This intervention addresses the immediate life-threatening situation of myocardial ischemia.
Choice C rationale
Obtaining one hour of echocardiogram readings would not be the most immediate intervention for a patient experiencing increased chest pain after taking sublingual nitroglycerin. While an echocardiogram can provide valuable information about the structure and function of the heart, it is not the first step in managing acute chest pain.
Choice D rationale
Decreasing the patient’s anxiety is an important aspect of care, but it is not the most immediate intervention for a patient experiencing increased chest pain after taking sublingual nitroglycerin. The priority is to address the physical cause of the chest pain.