# 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.

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> subject: System-Specific Assessments  
> category: ROR

## Question

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.

1

Continue pulse oximetry; do not start routine oxygen at SpO2 93 percent without respiratory distress, but provide oxygen if saturation falls below 90 percent

2

Obtain right-sided leads, maintain IV access and defibrillation readiness, and draw ordered urgent studies without delaying transfer for reperfusion

3

Give morphine 4 mg IV routinely as first-line treatment and administer nitroglycerin before assessing right ventricular preload dependence or blood pressure

4

Confirm the prehospital aspirin dose and administer the prescribed oral P2Y12 inhibitor after checking allergies, contraindications, and bleeding risk

5

Administer the prescribed IV unfractionated heparin after completing the focused anticoagulation and bleeding-safety assessment

6

Keep the catheterization team activated, continue rhythm and hemodynamic monitoring, and transfer the client immediately for primary PCI

## 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.

## In-depth explanation

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.

## Clinical scenario

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 target
Choose the complete pre-PCI bundle without delaying reperfusion or applying routine oxygen, morphine, or nitrates indiscriminately.

## Key concepts

- **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.

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