# A 60-year-old client arrives in the emergency department with crushing substernal chest pain rated 9/10 that radiates to the left arm and jaw. The 12-lead ECG shows ST elevation in leads II, III, and aVF, consistent with an acute inferior STEMI. Which interventions should the nurse anticipate as immediate priorities? Select all that apply. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=366730&lang=en > language: en > subject: Medical Emergencies > category: PA ## Question A 60-year-old client arrives in the emergency department with crushing substernal chest pain rated 9/10 that radiates to the left arm and jaw. The 12-lead ECG shows ST elevation in leads II, III, and aVF, consistent with an acute inferior STEMI. Which interventions should the nurse anticipate as immediate priorities? Select all that apply. 1 Give sublingual nitroglycerin without first checking blood pressure or assessing for right ventricular involvement, because inferior STEMI rarely affects the right ventricle 2 Apply oxygen at 10 L/min by nonrebreather mask to every client with STEMI regardless of the pulse oximetry reading 3 Activate the cardiac catheterization team to achieve primary PCI within 90 minutes of arrival at a PCI-capable hospital 4 Establish two large-bore IV access sites and obtain serial troponin, a basic metabolic panel, and coagulation studies without delaying reperfusion 5 Choose fibrinolytic therapy as first-line reperfusion when primary PCI can be performed at the hospital within 90 minutes 6 Administer aspirin 162 to 325 mg, chewed and swallowed, unless contraindicated ## Explanation Immediate STEMI care includes chewable aspirin 162 to 325 mg unless contraindicated (Choice 6), IV access and indicated laboratory testing without delaying reperfusion (Choice 4), and rapid catheterization-team activation for primary PCI with a 90-minute arrival-to-PCI goal at a PCI-capable hospital (Choice 3). Before giving nitroglycerin for an inferior STEMI, assess blood pressure and evaluate for right ventricular involvement because preload reduction can cause profound hypotension (Choice 1). Primary PCI is preferred when it can be delivered within the recommended time; fibrinolysis is considered when timely PCI is not available and no contraindication exists (Choice 5). Routine high-flow oxygen is not indicated when oxygenation is adequate; provide supplemental oxygen for hypoxemia, such as an SpO2 below 90%, or other clinical indications (Choice 2). ## In-depth explanation STEMI Initial Bundle 1. 12-lead ECG within 10 min of arrival 2. Aspirin 162-325 mg chewed (unless contraindicated) 3. Activate cath lab — door-to-balloon ≤ 90 min for PCI 4. Two large-bore IVs, troponin, BMP, coags 5. Nitroglycerin SL only after BP confirmed and right-sided ECG in inferior MI 6. Morphine for pain not relieved by nitroglycerin (controversial, use cautiously) 7. Oxygen only if SpO2 < 90% (no longer routine) Inferior MI (II, III, aVF) Caution Up to 40% have right ventricular involvement. RV is preload-dependent. Nitroglycerin and morphine can cause profound hypotension. Get right-sided ECG (V4R) first; if RV involvement, give IV fluids before considering nitrates. Memory Tip — "MOAN" MONA replaced by current evidence: Morphine cautious, Oxygen only if hypoxic, Aspirin chewed, Nitroglycerin BP-dependent. Caution PCI preferred when available within 90 min; fibrinolytics if PCI > 120 min away. Contraindications to fibrinolytics: active bleeding, recent stroke, recent surgery, severe HTN. ## Clinical scenario Scenario 60 y.o., crushing chest pain 9/10, radiating to left arm and jaw, diaphoretic, nauseated. ECG: ST-elevation II, III, aVF (inferior STEMI). VS: BP 138/82, HR 88, RR 22, SpO2 96% RA. Door-to-Balloon Workflow 0 min: arrival ≤ 10 min: 12-lead ECG, history, aspirin chewed, IV × 2 ≤ 20 min: cath lab activated, anticoagulation initiated ≤ 60 min: blood draws, additional antiplatelet (P2Y12 inhibitor) ≤ 90 min: balloon inflation in occluded artery Right-Sided ECG First For ANY inferior STEMI, obtain right-sided ECG (V4R) before nitroglycerin. ST-elevation V4R = RV involvement → AVOID nitrates and morphine, give IV fluid bolus instead. Red Flags - New murmur (papillary muscle rupture) - Hypotension after nitroglycerin (RV involvement) - New AV block (inferior MI affects SA/AV nodes) ## Key concepts - **STEMI vs NSTEMI vs UA** — STEMI: ST-segment elevation, complete coronary occlusion, requires immediate reperfusion. NSTEMI: positive troponin without ST-elevation, partial occlusion. Unstable angina (UA): chest pain at rest or with minimal exertion, negative troponin. STEMI gets primary PCI; NSTEMI/UA get risk-stratified medical management with possible delayed PCI. - **Door-to-balloon time** — Time from ED arrival to balloon inflation in the occluded coronary artery during primary PCI. ACC/AHA target: ≤ 90 minutes. Each 30-minute delay increases mortality. If PCI cannot be done within 120 minutes total, fibrinolytic therapy is given instead. - **Right-sided ECG (V4R)** — Lead V4 placed on the right chest mirror image, used to evaluate right ventricular involvement in inferior STEMI. ST-elevation in V4R suggests RV infarct, which is preload-dependent. 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