# 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.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=617417&lang=en  
> language: en  
> subject: Medical Emergencies  
> category: PA

## Question

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.

Condition

Select 1
Inferior STEMI with left ventricular failure
Acute pericarditis with myocarditis
Non-ST-elevation myocardial infarction
Inferior and right ventricular STEMI

Actions to take

Select 2
Give sublingual nitroglycerin 0.4 mg for the pain
Prepare for emergent primary PCI
Give the prescribed IV furosemide 40 mg dose
Infuse the prescribed 0.9% saline bolus
Plan angiography after the troponin trend returns

Parameters to monitor

Select 2
Pericardial friction rub
Blood pressure
Daily weight
ST-segment elevation on ECG
Serum B-type natriuretic peptide

## Explanation

Inferior ST elevation with reciprocal changes and ST elevation in V4R, together with hypotension, jugular venous distention, and clear lungs, indicates right ventricular infarction. The right ventricle depends on preload, so the nurse prepares for emergent reperfusion and gives the prescribed saline bolus. Nitroglycerin and diuretics lower preload and can worsen hypotension.

## In-depth explanation

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.

References
1MedlinePlus — Heart AttackHeart attack recognition and emergency reperfusion treatment
2American Heart Association — Warning Signs of a Heart AttackChest pressure radiating to the jaw with diaphoresis as ischemic warning signs

## Clinical scenario

Scenario
Crushing chest pressure with inferior ST elevation, reciprocal depression, ST elevation in V4R, hypotension, distended neck veins, and clear lungs.

## Key concepts

- **Reciprocal ST depression** — ST depression in leads facing the opposite wall of an ST-elevation injury, which supports infarction over pericarditis.
- **V4R** — A right-sided precordial lead; ST elevation there suggests right ventricular infarction.
- **Preload dependence** — A state in which cardiac output falls sharply when venous return is reduced, as in right ventricular infarction.

## Related questions

- [A nurse is caring for an alert adult client with type 1 diabetes who reports tremors, swea…](https://mymerci.kr/pages/nclex_q.php?qn_id=360524&lang=en)
- [A 58-year-old client arrives at the emergency department with crushing substernal chest pa…](https://mymerci.kr/pages/nclex_q.php?qn_id=362976&lang=en)
- [A 72-year-old client is brought to the emergency department by family who report that the …](https://mymerci.kr/pages/nclex_q.php?qn_id=363003&lang=en)
- [A 79-year-old client is admitted from a long-term care facility with diarrhea, decreased o…](https://mymerci.kr/pages/nclex_q.php?qn_id=363089&lang=en)
- [A 68-year-old client is admitted to the emergency department with suspected sepsis from a …](https://mymerci.kr/pages/nclex_q.php?qn_id=363987&lang=en)
- [A nurse is caring for an adult client in the emergency department who is suspected to have…](https://mymerci.kr/pages/nclex_q.php?qn_id=363993&lang=en)
- [A nurse is teaching a 72-year-old client with chronic heart failure (reduced ejection frac…](https://mymerci.kr/pages/nclex_q.php?qn_id=366202&lang=en)
- [A nurse is caring for an adult client admitted with diabetic ketoacidosis. Laboratory resu…](https://mymerci.kr/pages/nclex_q.php?qn_id=366294&lang=en)

## Read in another language

- [en](https://mymerci.kr/pages/nclex_q.php?qn_id=617417&lang=en)
- [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=617417&lang=ko)
- [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=617417&lang=ja)
- [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=617417&lang=zh-tw)
- [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=617417&lang=vi)

---

More free questions: [NCLEX-RN Practice](https://mymerci.kr/pages/nclex_bank.php?lang=en)

_For study reference only. Always follow current clinical guidelines and your institution’s protocols._