Coronary Artery Disease: Atherosclerosis, Angina, ACS & MI — NCLEX Nursing Lesson Anatomy & Physiology · RN Track · Medical-Surgical Body Systems · Cardiovascular System · Coronary Artery Disease Condition Lesson · NCLEX-PN / NCLEX-RN

From clogging arteries to a full heart attack—why the heart muscle starves, how to tell angina from an MI, and the reasoning behind every drug and "time is muscle" decision.

In this lesson

Lesson Objectives
Why This Matters
Disease Overview
Pathophysiology
Risk Factors
Signs & Symptoms
Nursing Assessment
Diagnostic Tests
Laboratory Tests
Medications
Nursing Interventions
Complications
Patient Education
Clinical Judgment
Clinical Connections
NCLEX High-Yield
Memory Aids
Case Study
Practice Questions
Key Takeaways
References

Lesson Objectives

Explain how atherosclerosis narrows coronary arteries and starves the heart muscle of oxygen.
Differentiate stable angina, unstable angina, and myocardial infarction (STEMI vs. NSTEMI) by cause and features.
Recognize an MI fast and justify the immediate treatments (aspirin, nitroglycerin, oxygen, ECG, reperfusion)—"time is muscle."
Explain the reasoning and safety behind the key cardiac medications and interpret troponin.
Apply the NCSBN Clinical Judgment model and answer NGN-style items on coronary artery disease.

Why This Matters

Prevalence: coronary artery disease (CAD) is the most common heart disease and the leading cause of death in the United States and worldwide. Its acute forms—acute coronary syndrome (ACS) and myocardial infarction (MI, "heart attack")—are among the most common medical emergencies. You'll care for these patients in the ED, cath lab, telemetry/ICU, and cardiac rehab.

Patient safety: a blocked coronary artery starves heart muscle of oxygen; if flow isn't restored quickly, the muscle dies (infarction), causing dangerous dysrhythmias, heart failure, and death. Rapid recognition and reperfusion save lives—"time is muscle."

NCLEX importance: heavily tested on recognizing chest pain/MI, the immediate protocol (aspirin, nitroglycerin, oxygen if hypoxic, 12-lead ECG, troponin), nitroglycerin safety, reperfusion (PCI/thrombolytics), cardiac medications, and complications (dysrhythmias, cardiogenic shock). It builds on the A&P of coronary perfusion (arteries fill in diastole) and oxygen supply/demand.

Why nurses encounter it constantly: CAD is everywhere given aging and risk factors; nurses screen, respond to chest pain, give and teach cardiac drugs, and support recovery and prevention.

Connecting to prior lessons From A&P, recall that the coronary arteries feed the heart muscle and fill during diastole, and that ischemia results when oxygen demand exceeds supply. From assessment, recall that chest pain with radiation, diaphoresis, and dyspnea is a red flag—and that women, diabetics, and older adults have atypical presentations.

Disease Overview

Coronary artery disease is a spectrum caused by atherosclerosis—plaque buildup that narrows the coronary arteries. Where a patient sits on the spectrum depends on how much the artery is blocked and whether a plaque has ruptured:

Condition	What's happening	Pain pattern
Atherosclerosis / stable CAD	Plaque narrows the artery; supply is limited but adequate at rest	Often none at rest
Stable angina	Narrowed artery can't meet increased demand (exertion/stress)	Predictable chest pain with exertion, relieved by rest and nitroglycerin
Unstable angina (ACS)	A plaque ruptures with partial clot; supply is critically reduced	New, worsening, or at-rest chest pain—an emergency; no permanent muscle death yet (troponin normal)
NSTEMI (ACS)	Partial blockage causing muscle injury/death (subendocardial)	MI symptoms; troponin elevated; no ST-elevation on ECG
STEMI (ACS)	Complete blockage → full-thickness muscle death	MI symptoms; ST-elevation on ECG + elevated troponin—needs emergent reperfusion

Analogy — the clogging pipe

Picture a coronary artery as a pipe slowly clogging with grease (plaque). At first the pipe is narrowed but water still flows—until you turn the demand up (exertion) and the trickle can't keep up: that's stable angina (rest and it settles). If a chunk of grease breaks loose and a clot forms, the pipe suddenly blocks: that's ACS—unstable angina (partial) up to a full heart attack (MI) when the pipe is completely plugged and the tissue downstream starts to die. The nurse's job in an MI is to reopen the pipe fast—before the muscle dies.

Pathophysiology

Normal physiology: open coronary arteries deliver oxygen-rich blood to the heart muscle (mostly during diastole). Supply matches the heart's oxygen demand. ↓ Atherosclerosis: over years, cholesterol/inflammation build plaque in the artery wall → the lumen narrows → blood flow is limited, especially when demand rises. ↓ Angina: when the narrowed artery can't meet increased oxygen demand (exertion, stress, cold), the muscle becomes ischemic → chest pain/pressure. In stable angina, rest/nitroglycerin restores balance; in unstable angina, a ruptured plaque + clot cuts supply critically even at rest. ↓ MI (heart attack): a plaque ruptures and a clot blocks the artery → the muscle downstream loses oxygen and begins to die (infarction) within ~20–40 minutes → chest pain not relieved by rest/nitro, with diaphoresis, dyspnea, and troponin release. ↓ How it progresses: dying muscle triggers dysrhythmias (the top early cause of death), pump failure (heart failure/cardiogenic shock), and, over time, scar tissue. Reopening the artery quickly (PCI or thrombolytics) salvages muscle—"time is muscle." NCLEX Clinical Pearl — angina vs. MI Stable angina: predictable, brought on by exertion, lasts a few minutes, and is relieved by rest and nitroglycerin; troponin normal. MI: pain is often more severe, occurs at rest, lasts >15–20 minutes, is NOT relieved by rest or nitroglycerin, comes with diaphoresis/nausea/dyspnea, and troponin rises. Pain unrelieved by rest/nitro = treat as an MI.

Risk Factors

Non-modifiable	Modifiable	Preventable / reducible
Age (older) Male sex (and postmenopausal women) Family history of early heart disease Genetics/ethnicity	Smoking, high LDL cholesterol, hypertension, diabetes Obesity, physical inactivity Poor diet, excess alcohol, stress	Smoking cessation Control BP, lipids, and glucose Heart-healthy diet, exercise, weight loss Statins and aspirin as indicated

High-risk populations: older adults, smokers, people with diabetes/hypertension/high cholesterol/obesity, those with a family history of early CAD, and postmenopausal women. Diabetics and older adults often have atypical or "silent" presentations.

Signs & Symptoms

Category	Findings & WHY they occur
Stable angina	Predictable chest pain/pressure/tightness with exertion, often substernal, sometimes radiating to the arm/jaw; relieved by rest and nitroglycerin. Ischemia from a supply-demand mismatch.
MI — classic	Sudden crushing/pressure-like substernal chest pain, often radiating to the left arm, jaw, or back; diaphoresis; nausea/vomiting; dyspnea; anxiety/"sense of doom"; pain NOT relieved by rest or nitroglycerin. Muscle is dying.
MI — atypical (high-yield)	Women, diabetics, and older adults may have fatigue, indigestion, shortness of breath, nausea, jaw/back/epigastric pain, or no chest pain ("silent MI"). Don't dismiss atypical symptoms.
Objective signs	Tachycardia or dysrhythmia, changes in BP, cool/clammy skin, S3/S4, crackles (if heart failure), low SpO₂, ECG changes (ST-elevation in STEMI).
Emergency findings	Ongoing chest pain unrelieved by nitro, a dangerous dysrhythmia, hypotension with poor perfusion (cardiogenic shock), or cardiac arrest.

Why "unrelieved by rest and nitroglycerin" changes everything Angina that doesn't resolve with rest and up to 3 nitroglycerin doses (5 minutes apart) signals that the artery is likely blocked—an MI in progress. This is the moment to treat as an emergency: call for help, obtain a 12-lead ECG, and follow the chest-pain protocol. Delay costs heart muscle.

Nursing Assessment

Subjective: chest pain assessment (PQRST—provocation, quality, region/radiation, severity, timing), associated symptoms (diaphoresis, nausea, dyspnea), what relieves it (rest/nitro?), risk factors, and medication use (including PDE5 inhibitors like sildenafil—important for nitro safety).

Objective: vital signs with SpO₂, heart rate/rhythm (telemetry), BP, heart/lung sounds, skin (cool/clammy), 12-lead ECG, and signs of poor perfusion or heart failure.

Priority / focused finding	Why it matters / action
Chest pain (character, relief, ECG)	Pain unrelieved by rest/nitro + ECG changes = MI—activate the protocol immediately.
Rhythm (telemetry)	Dysrhythmias are the top early cause of death—monitor and treat.
Blood pressure & perfusion	Hypotension with poor perfusion = cardiogenic shock—escalate.
Oxygenation	Give oxygen if hypoxic (SpO₂ low); support the ischemic muscle.
Nitro safety check (BP, PDE5i use)	Hold nitro if SBP low or recent sildenafil (severe hypotension risk).

When to notify / act now New or ongoing chest pain (especially unrelieved by nitro), ST-elevation or new ECG changes, a dangerous dysrhythmia, hypotension with poor perfusion, or acute dyspnea/pulmonary edema. These are time-critical emergencies.

Diagnostic Tests

Test	Purpose / why ordered	Findings & nursing considerations
12-lead ECG	Detect ischemia/injury and identify STEMI vs. NSTEMI	ST-elevation = STEMI (emergent reperfusion); ST-depression/T-wave changes = ischemia/NSTEMI. Obtain within 10 minutes of chest pain.
Cardiac catheterization / coronary angiography (PCI)	Visualize and open blocked arteries (angioplasty/stent)	The gold standard/treatment for STEMI; door-to-balloon goal ≤90 minutes. Post-procedure: monitor the access site (bleeding), pulses, and vitals; keep the leg straight (femoral); hydrate (contrast). Check for contrast/shellfish allergy.
Stress test (exercise or pharmacologic)	Provoke ischemia to assess stable CAD	Hold certain meds (e.g., beta-blockers/caffeine) per orders; monitor for chest pain/ECG changes.
Echocardiogram	Assess wall motion, function (EF), and complications	Noninvasive; identifies damaged/weak areas.
Chest X-ray	Evaluate heart size and pulmonary congestion	Rules out other causes; shows heart failure.

Laboratory Tests

Lab	Normal / expected	Significance
Troponin (I or T)	Very low/undetectable (lab-specific)	The key marker of myocardial injury/MI—rises within a few hours, stays elevated for days. Trended serially. Normal troponin with ACS symptoms suggests unstable angina; elevated = NSTEMI/STEMI.
CK-MB	Low (lab-specific)	Rises with heart-muscle damage (less specific than troponin); can help time/track infarction.
Lipid panel	LDL <100 mg/dL (lower if high-risk)	Assesses/guides statin therapy—an underlying driver of CAD.
BNP	<100 pg/mL	Elevated if the MI causes heart failure.
CBC, electrolytes, coagulation	Per lab	Baseline before anticoagulation/PCI; electrolyte imbalances cause dysrhythmias.

Trend interpretation Troponin is the star. A rising troponin with chest pain confirms myocardial injury (NSTEMI/STEMI); a normal troponin with ACS symptoms points to unstable angina (still an emergency). Serial troponins (e.g., on arrival and hours later) track the infarction. Also watch potassium/magnesium (dysrhythmia risk) and BNP (heart failure).

Medications

Immediate MI/ACS therapy — "MONA" (given per protocol/orders)

Drug	Why given & nursing/teaching
Aspirin (chewed)	Antiplatelet—prevents further clot growth; give early (chewable for fast absorption) unless contraindicated. A cornerstone of MI care.
Nitroglycerin	Vasodilator—dilates coronary arteries and reduces preload to relieve ischemic pain. Give up to 3 sublingual doses, 5 minutes apart; check BP before each (hold if SBP low). Contraindicated with PDE5 inhibitors (sildenafil/tadalafil) → severe hypotension. Side effects: headache, hypotension, dizziness.
Oxygen	Given if hypoxic (SpO₂ low)—supports the oxygen-starved muscle. (Routine oxygen isn't given if SpO₂ is normal.)
Morphine	For chest pain unrelieved by nitroglycerin—relieves pain/anxiety and reduces cardiac workload. Monitor BP and respirations.

Ongoing / secondary-prevention medications

Class / drug	Mechanism & key nursing/teaching
Antiplatelets — aspirin + clopidogrel/ticagrelor (dual therapy after a stent)	Prevent clotting (especially in-stent thrombosis). Bleeding precautions; don't stop early after a stent.
Anticoagulants — heparin	Prevent clot extension in ACS; monitor aPTT/bleeding.
Beta-blockers — metoprolol	Lower heart rate and contractility → reduce oxygen demand; don't stop abruptly; caution in asthma/bradycardia.
Statins — atorvastatin	Lower LDL and stabilize plaque; monitor liver enzymes; report muscle pain (rhabdomyolysis).
ACE inhibitors/ARBs	Protect the heart/reduce remodeling after MI; watch cough (ACE) and potassium.

Reperfusion therapy

PCI (percutaneous coronary intervention/stent) is the preferred treatment for a STEMI—door-to-balloon ≤90 minutes. If PCI isn't available quickly, thrombolytics ("clot busters," e.g., alteplase) dissolve the clot—watch for bleeding (the major risk; screen for contraindications like recent surgery/bleeding/stroke).

NCLEX testing points MI/ACS: aspirin (chew), nitroglycerin (3 doses/5 min apart, check BP, no PDE5i), oxygen if hypoxic, morphine for unrelieved pain, 12-lead ECG, troponin. STEMI → PCI ≤90 min (or thrombolytics—bleeding risk). Beta-blockers/statins/antiplatelets for prevention. Pain unrelieved by nitro = treat as MI.

Nursing Interventions

Priority	Intervention & WHY
Airway/Breathing	Monitor SpO₂; give oxygen if hypoxic; support ventilation if the MI causes pulmonary edema/failure—protect oxygen delivery to the heart.
Circulation (the focus)	Continuous telemetry for dysrhythmias, frequent BP, IV access; give MONA and reperfusion therapy; monitor perfusion and for cardiogenic shock.
Relieve ischemia & reduce workload	Rest (limit activity/oxygen demand), nitroglycerin, beta-blockers, and a calm environment—less demand + more supply saves muscle.
Rapid response to chest pain	Stay with the patient, obtain a 12-lead ECG within 10 minutes, notify the provider, and follow the protocol—"time is muscle."
Safety (post-PCI/bleeding)	Monitor the catheter site for bleeding/hematoma and distal pulses; bleeding precautions with antiplatelets/anticoagulants/thrombolytics.
Comfort	Pain relief (nitro/morphine), reduce anxiety (which raises demand), and reassure.
Patient education	Warning signs, medication adherence, nitroglycerin use, risk-factor control, and cardiac rehab.
Interdisciplinary	Cardiology/cath lab, dietitian, pharmacy, cardiac rehab, and social work.

Why oxygen supply vs. demand is the whole game Ischemic heart muscle is a supply-demand problem. Nursing care attacks both sides: increase supply (oxygen if hypoxic, nitroglycerin/reperfusion to open the artery) and decrease demand (rest, beta-blockers, calm, pain/anxiety control). Every intervention fits this simple frame.

Potential Complications

Complication	Early signs	Nursing / emergency response
Dysrhythmias (top early cause of death)	Irregular rhythm on telemetry, palpitations, syncope	Emergency: continuous monitoring, treat per ACLS, correct electrolytes; defibrillate VF/pulseless VT.
Cardiogenic shock	Hypotension, cool clammy skin, altered mentation, low output	Emergency: oxygen, inotropes/vasopressors, possible mechanical support; escalate.
Heart failure / pulmonary edema	Dyspnea, crackles, S3, edema	Sit upright, oxygen, diuretics, monitor; notify provider.
Reinfarction / extension	Recurrent chest pain, rising troponin	Repeat ECG/troponin, notify provider, prepare for reperfusion.
Post-PCI bleeding / stent thrombosis	Access-site bleeding/hematoma; recurrent chest pain	Hold pressure, monitor; maintain dual antiplatelet therapy.
Cardiac arrest	Unresponsive, no pulse	Emergency: begin CPR/ACLS, defibrillate as indicated.

Patient Education

Disease process: explain that CAD narrows the heart's arteries and that fast treatment of chest pain saves muscle. Lifestyle modifications: stop smoking, follow a heart-healthy (low saturated fat/sodium) diet, exercise (per cardiac rehab), lose weight, and control BP, cholesterol, and diabetes. Medication adherence: take antiplatelets/statins/beta-blockers as prescribed (do not stop dual antiplatelet therapy after a stent, or beta-blockers abruptly); understand nitroglycerin use. Nitroglycerin teaching: at chest pain, sit/stop activity and take one sublingual tablet; if not relieved, repeat every 5 minutes up to 3 doses—call 911 if pain persists after the first dose or 3 doses; store tablets in a dark, airtight container; expect a headache; rise slowly (hypotension); do not use with erectile-dysfunction drugs (sildenafil). Home care/follow-up: attend cardiac rehab, keep appointments and labs. Warning signs / when to seek emergency care: chest pain unrelieved by rest/nitro, spreading pain, severe dyspnea, sweating, or fainting—call 911.

Clinical Judgment (NCSBN Model)

Recognize cues: a 60-year-old reports crushing substernal chest pain radiating to the left arm and jaw for 30 minutes, with diaphoresis, nausea, and dyspnea; pain is not relieved by rest; BP 148/90, HR 102, SpO₂ 93%.
Analyze cues: classic chest pain unrelieved by rest + radiation + diaphoresis + dyspnea = acute coronary syndrome/MI—muscle may be dying.
Prioritize hypotheses: acute MI—rapid recognition, oxygenation, and reperfusion are the priority ("time is muscle").
Generate solutions: stay with the patient, obtain a 12-lead ECG within 10 minutes, give aspirin (chew) and nitroglycerin (check BP), oxygen since SpO₂ is low, draw troponin, place on telemetry and IV access, and notify the provider/activate the cardiac (STEMI) protocol; anticipate PCI.
Take action: deliver MONA per protocol, get the ECG/troponin, monitor rhythm, and prepare for reperfusion.
Evaluate outcomes: did pain, ECG, and perfusion improve; is the patient stable and heading to the cath lab? Continue monitoring for dysrhythmias and reinforce prevention/rehab at discharge.

Clinical Connections — commonly confused conditions

	Stable angina	Unstable angina	Myocardial infarction (MI)
Cause	Fixed narrowing; demand > supply with exertion	Ruptured plaque + partial clot	Ruptured plaque + occluding clot → muscle death
Pain	Predictable, exertional, brief; relieved by rest/nitro	New/worse/at-rest; not fully relieved—emergency	Severe, at rest, >15–20 min; NOT relieved by rest/nitro
Troponin	Normal	Normal (no death yet)	Elevated
ECG	Usually normal (or transient changes)	ST-depression/T-wave changes possible	ST-elevation (STEMI) or ST-depression (NSTEMI)
Priority nursing	Risk-factor control, nitro teaching	Treat as ACS—ECG, aspirin, monitor	ECG, aspirin/nitro/O₂, reperfusion (PCI/thrombolytics)

Also distinguish cardiac chest pain from non-cardiac causes (GERD, musculoskeletal, anxiety)—but when in doubt, treat chest pain as cardiac until proven otherwise, especially with risk factors.

NCLEX High-Yield Review

What the NCLEX Wants You to Know

Chest pain unrelieved by rest/nitro = MI 12-lead ECG, aspirin, nitro, O₂ if hypoxic, troponin—"time is muscle."
Nitro: 3 doses, 5 min apart, check BP No PDE5 inhibitors (sildenafil).
Troponin = MI marker Rises with muscle death; normal in unstable angina.
STEMI → PCI ≤90 min Thrombolytics if PCI unavailable (bleeding risk).
Atypical MI in women/diabetics/older adults Fatigue, nausea, dyspnea, jaw/back pain.

Common distractors: giving routine oxygen when SpO₂ is normal, repeating nitro without checking BP, giving nitro after sildenafil, delaying the ECG, and dismissing atypical symptoms. Priority interventions: recognize MI, ECG within 10 minutes, MONA per protocol, telemetry, and reperfusion. Expected vs unexpected: exertional angina relieved by rest/nitro is stable; at-rest pain unrelieved by nitro, ST-elevation, a dangerous rhythm, or hypotension are emergencies. Patient teaching: nitro use, call 911 rules, medication adherence (don't stop DAPT/beta-blockers), risk-factor control, cardiac rehab. Safety: dysrhythmia monitoring, post-PCI bleeding, nitro/PDE5i interaction. Delegation: RN assesses/interprets and manages the emergency; UAP can take vitals, obtain an ECG (if trained) and report, and assist with comfort/positioning—not interpret or titrate. Frequently tested meds: aspirin, nitroglycerin, morphine, metoprolol, atorvastatin, clopidogrel/heparin, thrombolytics. Critical values: troponin, potassium/magnesium, ECG changes. Most common mistakes: not obtaining the ECG fast, unsafe nitro use, and missing atypical MI.

Memory Aids

MI care "MONA" — Morphine (if unrelieved), Oxygen (if hypoxic), Nitroglycerin, Aspirin — plus a 12-lead ECG. (Give per current protocol.)
Angina vs. MI "Rest & nitro fixes angina, not an MI."
Nitro "3 & 5, then 911" — up to 3 doses, 5 minutes apart; call 911 if unrelieved (call after the first dose per current guidance).
Troponin = "the Truth about muscle death."
"Time is Muscle" — STEMI needs PCI ≤90 minutes.
Chest-pain history "PQRST" — Provocation, Quality, Region/Radiation, Severity, Timing.
No Nitro with the "little blue pill" — PDE5 inhibitors + nitro = dangerous hypotension.

Case Study — from admission to discharge

Admission. Mr. Osei, 62, with hypertension, high cholesterol, and a 30-pack-year smoking history, arrives in the ED with severe crushing substernal chest pressure for 40 minutes radiating to his left arm and jaw, with diaphoresis, nausea, and shortness of breath. The pain did not ease with rest. BP 150/92, HR 104, SpO₂ 92%. A 12-lead ECG shows ST-elevation in the anterior leads; troponin is elevated.

Step 1–2: Recognize & analyze cues

Cues: crushing chest pain unrelieved by rest + radiation + diaphoresis + dyspnea + ST-elevation + elevated troponin = STEMI (an acute MI). Muscle is dying—this is time-critical.

Step 3–4: Prioritize & plan

Priority: reperfusion and stabilization ("time is muscle"). Plan: stay with him, give aspirin (chew) and nitroglycerin (check BP), oxygen (SpO₂ low), morphine for unrelieved pain, telemetry, IV access, serial troponin, and activate the STEMI/cath-lab protocol for PCI (door-to-balloon ≤90 min); notify the provider.

Step 5: Take action

The nurse delivers MONA per protocol, keeps him on continuous telemetry (watching for dysrhythmias), applies oxygen, and he's taken emergently to the cath lab where the blocked LAD is opened with a stent (PCI). Dual antiplatelet therapy and a statin/beta-blocker are started.

Step 6: Evaluate & discharge

Chest pain resolves after reperfusion, troponin trends down, and no lethal dysrhythmia occurs. Discharge teaching: take dual antiplatelet therapy and other cardiac meds as prescribed (never stop them early after a stent), correct nitroglycerin use and 911 rules, stop smoking, heart-healthy diet, control BP/cholesterol, attend cardiac rehab, and seek emergency care for recurrent chest pain, dyspnea, or fainting.

NCLEX Practice Questions

Answer choices are numbered; the correct answer is given as a number.

1. A client reports chest pain that is not relieved after resting and taking three sublingual nitroglycerin tablets 5 minutes apart. The nurse should first:

Reassess in 30 minutes
Encourage the client to walk it off
Recognize a possible MI and obtain a 12-lead ECG while notifying the provider
Offer an antacid

Rationale

Answer: 3. Chest pain unrelieved by rest and nitroglycerin suggests an MI—obtain a 12-lead ECG immediately and follow the chest-pain protocol (aspirin, oxygen if hypoxic, notify). Waiting (1), walking (2), or an antacid (4) waste critical time.

2. Which laboratory result is most specific for confirming a myocardial infarction?

Elevated troponin
Elevated white blood cell count
Elevated BNP
Elevated potassium

Rationale

Answer: 1. Troponin is the most specific marker of myocardial injury/MI. WBC (2) is nonspecific, BNP (3) reflects heart failure, and potassium (4) is an electrolyte (dysrhythmia risk), not an MI marker.

3. Before administering sublingual nitroglycerin for chest pain, which nursing action is essential?

Check the client's temperature
Give it only with food
Administer it with an antihistamine
Check the blood pressure and ask about recent use of erectile-dysfunction drugs (e.g., sildenafil)

Rationale

Answer: 4. Nitroglycerin lowers blood pressure and is contraindicated with PDE5 inhibitors (severe hypotension), so check the BP and ask about sildenafil/tadalafil use before giving it. The other actions are not relevant safety checks.

4. A client is diagnosed with a STEMI. Which treatment does the nurse anticipate as the priority?

Scheduling an outpatient stress test
Emergent reperfusion with PCI (percutaneous coronary intervention)
Bed rest and observation only
A follow-up echocardiogram next week

Rationale

Answer: 2. A STEMI requires emergent reperfusion—PCI is preferred (door-to-balloon ≤90 minutes) to reopen the artery and save muscle. Delaying with outpatient testing (1, 4) or observation only (3) allows muscle to die.

5. Which client is most likely to have an atypical presentation of a myocardial infarction?

A 30-year-old man with classic crushing chest pain
A 25-year-old athlete with a muscle strain
A 72-year-old woman with diabetes reporting fatigue, nausea, and shortness of breath
A 40-year-old with heartburn after a large meal

Rationale

Answer: 3. Older adults, women, and diabetics often have atypical MI symptoms—fatigue, nausea, dyspnea, or jaw/back pain rather than classic chest pain. Option 3 fits this high-risk, atypical picture.

6. SATA. Which are appropriate immediate actions for a client with suspected acute MI? Select all that apply.

Obtain a 12-lead ECG within 10 minutes
Give chewable aspirin unless contraindicated
Administer nitroglycerin after checking blood pressure
Apply oxygen only if the client is hypoxic
Have the client ambulate to assess exercise tolerance

Rationale

Answers: 1, 2, 3, 4. A prompt ECG, aspirin, nitroglycerin (with a BP check), and oxygen if hypoxic are correct MI actions. Ambulating (5) increases oxygen demand and is dangerous during an acute MI—rest reduces workload.

7. SATA. Which discharge teaching points are appropriate after a stent placement for CAD? Select all that apply.

Continue dual antiplatelet therapy exactly as prescribed
Stop taking the beta-blocker as soon as you feel better
Attend cardiac rehabilitation
Stop smoking and follow a heart-healthy diet
Take nitroglycerin correctly and call 911 for unrelieved chest pain

Rationale

Answers: 1, 3, 4, 5. Maintaining dual antiplatelet therapy, cardiac rehab, lifestyle change, and correct nitro/911 use support recovery and prevent stent thrombosis. Stopping the beta-blocker abruptly (2) causes rebound effects and is dangerous.

8. Priority. A nurse is caring for four clients. Who should be assessed first?

A client with stable angina relieved by rest awaiting discharge
A client requesting nitroglycerin teaching
A client with a new stent asking about diet
A client with crushing chest pain unrelieved by nitroglycerin and diaphoresis

Rationale

Answer: 4. Crushing chest pain unrelieved by nitroglycerin with diaphoresis indicates an acute MI—a time-critical emergency and the priority. The others are stable or routine.

9. Delegation. Which task can the RN appropriately delegate to unlicensed assistive personnel (UAP) for a stable post-MI client?

Interpreting the ECG rhythm
Obtaining vital signs and assisting the client with hygiene, reporting any chest pain
Teaching about nitroglycerin
Titrating a nitroglycerin infusion

Rationale

Answer: 2. Vital signs, hygiene assistance, and reporting symptoms are within UAP scope. Interpreting ECGs (1), teaching (3), and titrating IV drips (4) require the licensed nurse.

10. NGN Case Study. A 58-year-old with diabetes and hypertension reports 45 minutes of substernal chest pressure radiating to the jaw, nausea, and dyspnea. Pain is unrelieved by rest. Vitals: BP 158/94, HR 108, SpO₂ 91%. ECG shows ST-elevation; troponin is elevated. He took sildenafil last night.

a) What is happening and which cues support it?
b) What are the priority nursing actions (and one key safety consideration)?

Model answer

a) What's happening: an acute STEMI (MI). Supporting cues: chest pressure unrelieved by rest with radiation, nausea/dyspnea, ST-elevation, elevated troponin, and hypoxia (SpO₂ 91%) in a high-risk diabetic/hypertensive patient.

b) Priority actions: 1) stay with him, obtain/confirm the 12-lead ECG, give chewable aspirin, apply oxygen (SpO₂ low), place on telemetry and IV access, and draw serial troponin; 2) activate the STEMI/cath-lab protocol for emergent PCI (door-to-balloon ≤90 min); 3) manage pain and reduce workload (rest, calm). Key safety consideration: he took sildenafil, so nitroglycerin is contraindicated (risk of severe hypotension)—hold nitro and use alternative pain management (e.g., morphine) per orders while proceeding to reperfusion. Evaluate pain relief, ECG/troponin trend, rhythm, and perfusion.

Key Takeaways

CAD is a spectrum from atherosclerosis → stable angina → ACS (unstable angina, NSTEMI, STEMI)—all rooted in a coronary oxygen supply-demand mismatch.
Stable angina is exertional and relieved by rest/nitro (troponin normal); an MI is at-rest pain NOT relieved by rest/nitro with a rising troponin.
MI protocol: 12-lead ECG within 10 min, aspirin (chew), nitroglycerin (3 doses/5 min, check BP, no PDE5i), oxygen if hypoxic, morphine for unrelieved pain, troponin, telemetry—"time is muscle."
STEMI → emergent PCI (door-to-balloon ≤90 min); thrombolytics if PCI is unavailable (bleeding risk).
Nursing attacks both sides of the equation: increase oxygen supply (O₂/reperfusion/nitro) and decrease demand (rest, beta-blockers, calm, pain control).
Watch for dysrhythmias (top early cause of death), cardiogenic shock, and heart failure; after a stent, never stop dual antiplatelet therapy or beta-blockers abruptly.
Atypical MI (fatigue, nausea, dyspnea, jaw/back pain) is common in women, diabetics, and older adults—don't dismiss it.

References

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Assessment Technologies Institute. (2023). ATI RN adult medical-surgical nursing review module (12th ed.). ATI Nursing Education.
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American Heart Association. (2024). Heart attack symptoms, diagnosis, and treatment. https://www.heart.org
Centers for Disease Control and Prevention. (2024). Coronary artery disease & heart attack. U.S. Department of Health and Human Services. https://www.cdc.gov/heartdisease

Coronary Artery Disease

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Welcome & Getting Started

Launch RN Simulator

Wellness Center

Nursing Foundations

Fundamentals & Safety

Pharmacology

Dosage Calculations

Leadership, Management & Delegation

Medical-Surgical Body Systems

Neurological System

Sensory System

Endocrine System

Respiratory System

Cardiovascular System

Hematologic/Immune/Lymphatic System

Gastrointestinal (GI) System

Renal & Genitourinary

Reproductive System

Musculoskeletal System

Integumentary System

Specialty Areas

Maternity

Infectious Diseases

Pediatrics

Mental Health

NCLEX Success Center

Clinical Judgment Practice

Prioritization Practice

Delegation Practice

Lab Values

Final Review