Stage 4 — Generate solutions. The inferior STEMI and right ventricular involvement are confirmed. Which actions should the nurse implement now while preparing for primary PCI? Select all that apply.
Select All That Apply
Choose your responses, then check the answer.
Explanation
Five coordinated actions Appropriate care includes oxygenation surveillance without routine oxygen; right-sided ECG, IV access, laboratory sampling, and defibrillation readiness; ordered antiplatelet and anticoagulant therapy after safety checks; and immediate monitored transfer for primary PCI. Routine morphine is not first-line ACS therapy, and nitrate administration before hemodynamic and right-ventricular assessment can cause harmful hypotension in a preload-dependent client.
Step 1 — Keep reperfusion central Diagnostic testing, IV access, medication safety checks, and monitoring occur while the catheterization team mobilizes; they do not create a serial delay before transfer.
Step 2 — Match oxygen to hypoxemia At SpO2 93 percent with unlabored breathing, continue pulse oximetry rather than giving routine oxygen. Provide oxygen if saturation falls below 90 percent or another clinical indication develops.
Step 3 — Use medications deliberately Confirm aspirin and give the prescribed P2Y12 inhibitor and anticoagulant after focused contraindication and bleeding checks. Morphine is reserved for persistent pain despite other therapy and can delay oral P2Y12 absorption. Right ventricular involvement increases sensitivity to preload reduction, so nitrate use requires hemodynamic assessment and team direction.
NCLEX rule Select actions that advance reperfusion safely in parallel and reject routine treatments that ignore the client’s current physiology.
Scenario (Stage 4 — Generate solutions)Right-sided lead V4R is elevated, BP is 138/86, lungs are clear, and SpO2 is 93 percent on room air. The catheterization laboratory is already activated.
Clinical judgment targetChoose the complete pre-PCI bundle without delaying reperfusion or applying routine oxygen, morphine, or nitrates indiscriminately.
Primary PCI pathway — Immediate catheterization-laboratory activation and coordinated transfer for mechanical reperfusion of the occluded coronary artery.
Right ventricular preload dependence — Reduced right ventricular output may worsen abruptly when venous return falls, so hemodynamics and medication effects require close assessment.
Selective oxygen use — Supplemental oxygen is indicated for hypoxemia but is not routine when saturation is at least 90 percent without respiratory distress.