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NCLEX Questions on Triage – How to Answer Them

It is likely that you will see a cardiac triage question on the NCLEX as chest pain accounts for over 8 million visits to the Emergency Departments (ED) in the US annually, making it one of the most common complaints (Natsui et. al., 2021). This is definitely a protocol in most EDs and one that you should be comfortable with triaging and managing proactively within your nursing scope of practice and judgment.

So a case then:

A 57-year-old African American male presents to your Emergency Department at 2200 complaining of chest pain that began at dinner and has lasted for over two hours. He has a prior history of hypertension for which he is on lisinopril 40mg PO daily and he smokes 1/2 pack a day. He weighs 240 lbs and is 5'6''. He is accompanied by his worried wife and his occupation is a business executive. He did try to take two Tums at dinner but it didn't relieve his chest pain. His pain is an 8/10 and is radiating up his sternum. It is intermittent and activity makes it worse. He was brought directly back into your ED bay and his vital signs are 170/90, heart rate of 98, respirations 27, 97% pulse oximetry on room air, and temperature of 98.9 degrees F.

The first things you would do for this patient would include:

A. Put him on a cardiac monitor, place on 2 liters of oxygen, and draw a set of cardiac enzymes and a BNP before continuing.

B. Put him on a cardiac monitor, place an IV, do a history and physical exam, give an appropriate dose of aspirin, obtain an EKG and chest x-ray, and place on 2 liters of oxygen.

C. Put him on a cardiac monitor, place an IV, do a history and physical exam, give an appropriate dose of aspirin, obtain an EKG, and place on 2 liters of oxygen.

D. Call a code while placing him on a cardiac monitor and 2 liters of oxygen

The Rationale:

Remember that in chest pain patients - your first priority will be to help gather subjective and objective data to diagnose or rule out life-threatening causes. These include acute coronary syndrome, aortic dissection, pulmonary embolism, tension pneumothorax, pericardial tamponade, and mediastinitis. Then you will move on to secondary significant but not typically fatal diagnoses.

(A) is a good answer however includes lab draws that should wait until the initial work-up rules out STEMI or aortic dissection.
(B) is the best answer based on a stable cardiac pain algorithm as described in current literature. Many protocols are written in the ED to allow nurses to use their judgment and follow a protocol when seeing chest pain patients. As this is a stable patient, these things are important in the algorithm of differential diagnoses and ruling out potentially life-threatening events.

(C) is a good answer but lacks the chest x-ray. This may seem extraneous, but a radiograph helps diagnose tension pneumothorax, pulmonary embolism, and pericardial tamponade.

(D) this would be appropriate in an unstable chest pain patient but his vital signs, while altered are essentially stable.

Reference

UpToDate. 2020. Evaluation of Chest Pain in the Emergency Department.

The Process

So the NCLEX loves to ask questions like this. They are looking for the best answer. But they love to mix answers with good answers and usually at least one distracting answer that competes well with the best answer and tempts you to choose it.

One test-taking strategy is to use the process of elimination to cut down 4 answers to at least 2 best choices and then choose between them if you are unsure. A 50% chance is better than a 25% chance of guessing.

Before you eliminate any answers, read the question and ask yourself "what are they really asking?". In this case, it is what are the priority nursing interventions for a cardiac pain patient? Then read through every answer before starting to eliminate.

After you read through the answers restate the question " Are these the priority nurse interventions...then read (A)". Your answer should be no, these are good but not the priority. Repeat that process with the other answers and try to eliminate 2.

In this case, it should be pretty clear that (A) is secondary and (D) is not correct because he is stable. When you get down to choose between (B) and (C) it is essentially coming down to your knowledge of how important a chest x-ray is in ruling out differential diagnoses of chest pain. But hey, you have a 50/50 chance if you didn't know and chances are you know.

Thanks for reading

- Nurse Amy

Reference

Natsui, S., Sun, B. C., Shen, E., Redberg, R. F., Ferencik, M., Lee, M.-S., Musigdilok, V., Wu, Y.-L., Zheng, C., Kawatkar, A. A., & Sharp, A. L. (2021). Higher Emergency Physician Chest Pain Hospitalization Rates Do Not Lead to Improved Patient Outcomes. Circulation: Cardiovascular Quality and Outcomes, 14(1). https://doi.org/10.1161/circoutcomes.119.006297