Your patient with an ACUTE INFERIOR WALL MI reports crushing chest pain, 7/10.
YOU ASSESS...
📉 BP 84/50
🫀 Jugular venous distention
🫁 Lungs clear bilaterally
💓 HR 58
The MAR shows PRN sublingual nitroglycerin for chest pain.
What should the nurse do NEXT?
2/3
Your Turn
Which response is BEST?
If you chose A...
✕ Not so fast.
Why?
✓Chest pain in an MI usually means nitro. That's the protocol reflex.
!But look at the cues together...
🪥 The cue cluster:
• BP 84/50
• JVD
• Lungs CLEAR
• Inferior wall MI
!This pattern points to right ventricular involvement. The RV is preload dependent.
⚠Nitro drops preload. In RV infarction, one SL tab can collapse the blood pressure.
💡 CJMM PEARL
Don't treat the order set. Treat the physiology.
Curious about the other choices?
If you chose B...
! Position won't fix perfusion.
Why?
✓You paused before reaching for a risky medication. Good instinct.
!But high Fowler's reduces venous return, and venous return is the one thing holding this patient's cardiac output up.
🔍 Think preload.
This patient needs MORE blood returning to the heart, not less. Sitting them straight up pools blood away from a right ventricle that is already failing, and it delays the real priority: restoring perfusion and escalating.
Curious about the other choices?
If you chose C...
✓ Excellent choice!
Why?
🔍You connected the cluster: inferior MI + hypotension + JVD + clear lungs = RV infarction until proven otherwise.
💧The RV is preload dependent. Nitro and diuretics strip preload; IV fluids restore it.
👤You protected perfusion first and escalated. Anticipate a right-sided ECG to confirm.
⭐ You treated the physiology, not the protocol.
Curious about the other choices?
If you chose D...
⚠ The JVD trap.
Why?
✓It sounds logical. Distended neck veins usually mean fluid overload.
!Except... the lungs are CLEAR and the BP is 84/50. This is not left-sided congestion.
💉 JVD + clear lungs + hypotension in an inferior MI means the RIGHT ventricle is failing. Furosemide would strip the preload it depends on and deepen the shock.
💡 CJMM PEARL
JVD does not automatically mean give Lasix. Ask WHICH ventricle is struggling first.
Curious about the other choices?
3/3
CJMM Debrief
This question wasn't really about nitroglycerin. It was about recognizing WHICH VENTRICLE was failing, because the treatment is opposite.
🔍
Recognize cues
What's going on?
🧠
Analyze cues
What do they mean?
📋
Prioritize hypotheses
What's the priority?
🏃
Generate solutions
What can we do?
✓
Take action
Do the right thing.
📈
Evaluate outcomes
Did it help?
🎯 THE TAKEAWAY
Same low BP as last week's heart failure patient. Opposite treatment.
Protocols don't make decisions. Nurses who understand physiology do.