A client reports shortness of breath and chest pressure radiating down the left arm. ECG shows ST segment elevation in leads II, III, aVF, and V4R. Which action should the nurse implement first?

A client reports shortness of breath and chest pressure radiating down the left arm. ECG shows ST segment elevation in leads II, III, aVF, and V4R. Which action should the nurse implement first?

• A. Infuse 0.9% sodium chloride bolus
• B. Administer morphine
• C. Administer nitroglycerin sublingual
• D. Start a heparin infusion

Answer: (A)

In this scenario the underlying issue is an inferior STEMI with right ventricular involvement. The right ventricle relies on adequate venous return (preload) to fill and pump blood toward the left ventricle. When the right ventricle is compromised, supporting preload is the first priority to maintain cardiac output and blood pressure. Giving a normal saline bolus increases venous return to the right heart, improves right ventricular filling, and thereby boosts left ventricular stroke volume and overall cardiac output. Medications like nitroglycerin or morphine reduce preload by venodilation, which can worsen hypotension in a right ventricular infarct, so they’re avoided initially. Starting heparin infusion is important as part of ACS management, but it does not quickly address the immediate hemodynamic instability.

In this scenario the underlying issue is an inferior STEMI with right ventricular involvement. The right ventricle relies on adequate venous return (preload) to fill and pump blood toward the left ventricle. When the right ventricle is compromised, supporting preload is the first priority to maintain cardiac output and blood pressure. Giving a normal saline bolus increases venous return to the right heart, improves right ventricular filling, and thereby boosts left ventricular stroke volume and overall cardiac output.

Medications like nitroglycerin or morphine reduce preload by venodilation, which can worsen hypotension in a right ventricular infarct, so they’re avoided initially. Starting heparin infusion is important as part of ACS management, but it does not quickly address the immediate hemodynamic instability.