An adult has crushing chest pressure and ST elevation in leads II, III, and aVF. Blood pressure is 84/56 mm Hg, jugular veins are distended, and lungs are clear. Complete the emergency plan.
Drop-down Cloze
Choose your responses, then check the answer.
Explanation
Inferior STEMI with hypotension, jugular venous distention, and clear lungs suggests right ventricular infarction. Right-sided leads such as V3R and V4R help confirm right ventricular involvement. Nitroglycerin can further reduce preload and worsen hypotension, so it is avoided while the client is hypotensive. The STEMI reperfusion pathway is activated immediately rather than delaying for an outpatient test or symptom resolution.
Correct Answer Identify possible right ventricular infarction, obtain right-sided ECG leads, and avoid nitroglycerin during hypotension while activating immediate reperfusion.
Why It Fits The right ventricle is preload dependent. Venodilation can worsen shock when right ventricular filling is already impaired.
Clinical Picture Clear lungs with elevated neck veins and hypotension in an inferior STEMI is the important cluster, not one finding in isolation.
Memory Link Inferior STEMI plus clear lungs and high neck veins: think right side and protect preload.
NCLEX Rule Confirm suspected right ventricular involvement without delaying the STEMI reperfusion pathway, and avoid preload-reducing nitrate therapy during hypotension.
Why the Alternatives Fail Stable angina, routine stress testing, or discharge does not fit an unstable STEMI. Giving nitrate despite hypotension can worsen perfusion.
Sources
12025 ACC/AHA Acute Coronary Syndromes Guideline
22026 NCLEX-RN Test Plan
The inferior STEMI pattern plus hypotension, elevated jugular venous pressure, and clear lungs raises concern for right ventricular involvement and preload-sensitive shock.