A 64-year-old client arrives at the emergency department with crushing chest pressure radiating to the jaw that began 40 minutes ago. The skin is cool and clammy. Vital signs: blood pressure 88/56 mm Hg, heart rate 58/min, respiratory rate 20/min, oxygen saturation 95% on room air. Jugular veins are distended with the head of the bed at 30 degrees, and the lungs are clear bilaterally. The 12-lead ECG shows ST elevation in leads II, III, and aVF with ST depression in I and aVL; a right-sided lead V4R also shows ST elevation. No friction rub is heard. Initial troponin is elevated. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Quick answer
Inferior STEMI with right ventricular infarction. Prepare the client for emergent primary PCI and give the prescribed saline bolus. Monitor blood pressure and ST-segment elevation.

Why this is correct
Localized ST elevation in II, III, and aVF with reciprocal depression in I and aVL is a STEMI pattern, not pericarditis. ST elevation in V4R plus hypotension, distended neck veins, and clear lungs shows a failing right ventricle rather than left ventricular failure. Reperfusion restores blood flow to the heart muscle, and cautious volume keeps up right-ventricular preload. Blood pressure shows whether preload support is working, and ST-segment resolution shows whether reperfusion succeeded.

Easy analogy or mental picture
Picture the right ventricle as a weak pump that only works when the inflow pipe is full. Nitroglycerin and diuretics drain the inflow pipe; a fluid bolus fills it.

Memory hook
Inferior MI plus low BP plus clear lungs: check V4R, fill the tank, skip the nitro.

NCLEX decision rule
In chest pain, pair the ECG pattern with the hemodynamic picture before choosing standard ACS actions. A 'routine' ACS drug can be the wrong choice for this client.

Why the other choices are wrong
Nitroglycerin is standard chest-pain care, but it is contraindicated when the client is hypotensive and has right ventricular infarction. Furosemide and daily weight or BNP fit left ventricular failure, which would cause crackles, not clear lungs. Waiting for the troponin trend before angiography is the NSTEMI timeline; ST elevation calls for immediate reperfusion. A friction rub tracks pericarditis, which causes diffuse ST elevation without reciprocal depression.