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The correct answer is A.

Correct Answer: A - Administer oxygen if SpO₂ is <90% and notify the Rapid Response Team

Why A is correct

In a suspected STEMI (ST-elevation myocardial infarction), the nurse's first priority follows the principle: assess and stabilize airway/breathing first, then escalate. Option A correctly combines two simultaneous first-line nursing actions:
  1. Oxygen only if SpO₂ < 90% - This is consistent with current guidelines (AHA/ACC). Routine oxygen in normoxic MI patients is not indicated and can actually be harmful (increases infarct size by causing coronary vasoconstriction). Supplemental O₂ is appropriate only when saturation drops below 90%.
  2. Notify the Rapid Response Team (RRT) - This triggers the institutional response chain and is the fastest way to ensure the patient gets emergent care (cardiology consult, cath lab activation, etc.). Time-to-treatment is critical in STEMI.

Why the other options are wrong (or not FIRST)

OptionWhy it's NOT the first priority
B - Sublingual nitroglycerinNot the first action. Must check blood pressure first - nitroglycerin is contraindicated if BP is low (<90 mmHg systolic) or if the patient took a PDE-5 inhibitor (e.g., sildenafil). Also contraindicated in inferior STEMI with RV involvement.
C - Morphine IVMorphine is no longer routinely recommended in STEMI (evidence suggests it may worsen outcomes by delaying P2Y12 inhibitor absorption). It is not a first-priority nursing action.
D - 12-lead ECGWhile a 12-lead ECG is essential, the stem already states ST-segment elevation is present on the ECG - so it has already been done. Repeating it is not the priority.

NCLEX Strategy: ABC + Maslow + Prioritization

For NCLEX, use the ABC framework (Airway, Breathing, Circulation) plus "Assess before you act" and "Escalate when life is threatened." In this scenario:
  • The patient's breathing status (SpO₂) must be checked first
  • The Rapid Response Team must be called immediately because this is a life-threatening emergency
  • Medications (nitroglycerin, morphine) come after assessment and physician orders
The answer is A.
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