NCLEX · Cardiac Care

A client presents with crushing chest pain radiating to the left arm. ECG shows ST elevation. What is the priority intervention?

Correct answer

Initiate the STEMI protocol: oxygen, aspirin, nitroglycerin, IV access, prepare for emergent reperfusion (PCI within 90 minutes or thrombolytics within 30 minutes if PCI unavailable)

  1. A Document the symptoms and reassess in an hour
  2. B Give oral antacids
  3. C Discharge home with follow-up
  4. D Initiate the STEMI protocol: oxygen, aspirin, nitroglycerin, IV access, prepare for emergent reperfusion (PCI within 90 minutes or thrombolytics within 30 minutes if PCI unavailable)

Why this is the answer

ST-elevation myocardial infarction (STEMI) is a medical emergency where coronary occlusion is causing actively-progressing myocardial damage. 'Time is muscle' — delays in reperfusion increase infarct size and worsen outcomes. Standard initial management (often remembered as MONA-BASH or similar mnemonics, though MONA is no longer routine): (1) Oxygen if SpO2 below 90% (no longer routine for everyone — supplemental O2 may worsen outcomes in non-hypoxic patients); (2) Aspirin 325 mg chewed (decreases platelet aggregation, reduces mortality); (3) Nitroglycerin sublingual (vasodilation, reduces preload and afterload, relieves ischemia — contraindicated in inferior MI with right ventricular involvement, sildenafil use in 24 hrs, severe hypotension); (4) Morphine for pain not relieved by nitrates (use cautiously); (5) IV access and continuous monitoring; (6) Reperfusion: PCI (percutaneous coronary intervention) within 90 minutes from first medical contact is gold standard; thrombolytics if PCI unavailable within timeframe. Other meds: beta-blocker, statin, ACE inhibitor.
Source: NCLEX-RN, Cardiac — STEMI Management

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About this topic: Cardiac Care

Cardiac care questions cover chest pain assessment, MI and heart failure management, dysrhythmia recognition, cardiac medications and the post-procedure care after catheterisation. This is one of 10 RN: Physiological Integrity questions on cardiac care, each with a full explanation on a single study page.

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