The nurse cares for a client with chest pain in the emergency department Review the electronic health record. For each nurse action, click to specify if the action is indicated or not indicated to implement next.

The patient presents with an acute coronary syndrome (ACS), specifically an evolving ST-elevation myocardial infarction (STEMI) involving the lateral leads (V5–V6), which suggests left ventricular ischemia. The client shows ECG evidence of myocardial injury with hemodynamic instability, including hypotension and tachycardia after nitroglycerin administration. Management priorities include restoring coronary perfusion, preventing lethal dysrhythmias, and preparing for emergent reperfusion therapy via percutaneous coronary intervention (PCI). Rationale: • Continuous cardiac monitoring: The client is experiencing an acute ST-elevation myocardial infarction with evolving hemodynamic instability. Continuous cardiac monitoring is essential to detect life-threatening dysrhythmias such as ventricular tachycardia or ventricular fibrillation, which are common complications during acute myocardial ischemia. Continuous monitoring is a critical safety intervention that allows immediate recognition and treatment of rhythm changes in real time. • Administer a third dose of nitroglycerin: Nitroglycerin is contraindicated at this point because the client’s blood pressure has dropped to 89/56 mmHg. Further doses could worsen hypotension and reduce coronary perfusion, increasing risk of cardiogenic shock. According to protocol, nitroglycerin should be withheld when systolic BP is below 90 mmHg or when significant hypotension is present. • Precautionary placement of defibrillator pads: STEMI significantly increases the risk of life-threatening ventricular dysrhythmias such as ventricular tachycardia or ventricular fibrillation. Defibrillator pads should be placed early to allow rapid response if the client deteriorates. This is a critical safety intervention in acute myocardial infarction with instability. It ensures immediate access to life-saving defibrillation if needed. • Prepare for transcutaneous pacing: Transcutaneous pacing is used for symptomatic bradycardia or high-grade atrioventricular blocks, which are not present in this client. The ECG shows ST elevation without evidence of conduction block or bradyarrhythmia. The current issue is ischemia with hypotension, not bradycardia requiring pacing support. • Prepare for transport to cardiac catheterization lab: The client is experiencing an acute STEMI, which requires immediate reperfusion therapy via percutaneous coronary intervention (PCI). Transport to the cardiac catheterization lab is the definitive priority to restore coronary blood flow and minimize myocardial damage. Time-sensitive intervention is critical (“time is muscle”). This is the most important definitive treatment step. • Apply oxygen via nasal cannula: Although oxygen saturation is near normal, the client is experiencing acute myocardial ischemia with hypotension. Supplemental oxygen supports myocardial oxygen delivery and reduces ischemic burden during acute infarction. Oxygen therapy is indicated in unstable ACS patients, especially with hemodynamic changes. It supports tissue perfusion while awaiting definitive intervention.