# A patient with suspected acute coronary occlusion arrives 35 minutes after sudden pressure-like chest discomfort with diaphoresis and nausea. The ECG shows ST elevation in V2–V4. Which time-critical nursing actions are appropriate while preparing the patient for primary PCI? Select all that apply.

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> url: https://mymerci.kr/pages/nclex_q.php?qn_id=372720&lang=en  
> language: en  
> subject: Medical Emergencies  
> category: PA

## Question

A patient with suspected acute coronary occlusion arrives 35 minutes after sudden pressure-like chest discomfort with diaphoresis and nausea. The ECG shows ST elevation in V2–V4. Which time-critical nursing actions are appropriate while preparing the patient for primary PCI? Select all that apply.

1

Delay aspirin and other antiplatelet therapy until coronary angiography identifies the culprit lesion and the interventional cardiologist confirms that the anticipated procedural bleeding risk is acceptable

2

Notify the interventional cardiology team immediately and expedite transfer to the catheterization suite within the facility reperfusion target

3

Check blood pressure and recent phosphodiesterase-5 inhibitor use before giving sublingual nitroglycerin; reserve opioid analgesia for pain that persists despite appropriate anti-ischemic therapy

4

Maintain continuous cardiac monitoring with defibrillation capability and repeat the ECG if symptoms or rhythm changes occur

5

Obtain intravenous access and collect ordered baseline specimens without delaying transfer for reperfusion

6

Give 162 to 325 mg of chewable aspirin promptly unless allergy or another contraindication is present

## Explanation

Notify the interventional cardiology team immediately and expedite transfer to the catheterization suite within the facility reperfusion target (Choice 2). Check blood pressure and recent phosphodiesterase-5 inhibitor use before sublingual nitroglycerin; reserve opioid analgesia for pain that persists despite appropriate anti-ischemic therapy (Choice 3). Maintain continuous cardiac monitoring with defibrillation capability and repeat the ECG if symptoms or rhythm change (Choice 4). Obtain IV access and ordered baseline specimens without delaying reperfusion (Choice 5). Give 162 to 325 mg of chewable aspirin promptly unless contraindicated (Choice 6). Delaying all antiplatelet therapy until angiography is unsafe because aspirin is an immediate foundational treatment for suspected STEMI when not contraindicated (Choice 1).

## In-depth explanation

Anchor STEMI care around three time targets and one acronym. (1) Door-to-ECG ≤10 minutes — establishes diagnosis. (2) Door-to-balloon ≤90 minutes — primary PCI; if PCI not available within 120 minutes, give fibrinolytics within door-to-needle ≤30 minutes (no bleeding contraindications). (3) Activate cath lab the moment ST elevation is recognized. Mnemonic MONA-B: Morphine (refractory pain), Oxygen (only if SpO2<90), Nitroglycerin (SBP >90, no PDE-5, no RV infarct), Aspirin (chewable 162-325 mg), Beta-blocker (within 24h if no contraindication). DAPT — aspirin plus P2Y12 inhibitor — is started immediately at STEMI recognition, not delayed for catheterization. Other essentials: high-intensity statin, anticoagulation (heparin/bivalirudin per protocol), ACE inhibitor within 24 hours. Watch for complications: VT/VF (highest first 4 hours), cardiogenic shock, papillary muscle rupture, ventricular septal rupture, pericarditis, and Dressler syndrome. Inferior STEMI requires V4R lead — RV infarct contraindicates nitrates and morphine because both worsen RV preload.

## Clinical scenario

Emergency department, fast-track room. Patient: 58-year-old male with HTN, hyperlipidemia, and 30 pack-year smoking history. Arrived 25 minutes ago with crushing substernal chest pain (10/10), diaphoresis, nausea. VS: BP 142/88, HR 102, RR 22, SpO2 96% RA. ECG: 3 mm ST elevation V2-V4 with reciprocal changes II/III/aVF. Triage nurse hands off to bedside nurse who is initiating STEMI bundle.

## Key concepts

- **Door-to-Balloon Time** — Quality measure tracking time from emergency department arrival to first balloon inflation during primary PCI for STEMI; target less than 90 minutes; faster reperfusion reduces myocardial necrosis and mortality
- **MONA-B Mnemonic** — Mnemonic for early STEMI pharmacologic management: Morphine for refractory pain, Oxygen if SpO2 below 90 percent, Nitroglycerin if SBP greater than 90 and no PDE-5 inhibitor use, Aspirin chewable 162 to 325 milligrams, Beta-blocker within 24 hours if no contraindication
- **Dual Antiplatelet Therapy (DAPT)** — Combination of aspirin and a P2Y12 inhibitor (clopidogrel, ticagrelor, or prasugrel) given as a loading dose at STEMI recognition and continued for at least 12 months after PCI to prevent stent thrombosis and recurrent events

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