A client pushes his call light and tells the nurse his chest is hurting. The nurse sees his oxygen saturation is 88%. The nurse’s first intervention is to

  • perform an ECG.
  • administer oxygen.
  • administer morphine IV.
  • call the Rapid Response Team.
Number 2 is correct.
The nursing priority is to administer oxygen in accordance with the airway, breathing, and circulation priority model. Once the client is receiving supplemental oxygen, the nurse can assess and further intervene.