NCLEX-RN® NGN Case Study: Adult with Crushing Chest Pain and Possible STEMI

An NGN case study on a 58-year-old with substernal chest pressure radiating to the jaw — which cues to highlight, how to rank acute coronary differentials, and the safe order of early-MI nursing actions.

A chest-pain case that rewards calm sequencing

A 58-year-old arrives at the emergency department with crushing substernal chest pressure that started 40 minutes ago while shovelling snow. The pressure radiates into the left jaw and arm. The client is diaphoretic, anxious, and short of breath, and tells you, "I thought I was just out of shape."

The story is simple on the surface and dangerous underneath. The client has hypertension, smokes a pack a day, and quietly stopped taking a statin after a refill ran out three months ago. A nurse hands you a 12-lead and a set of vitals while a family member describes a father who "had something with his heart" in his fifties.

That is the entire opening of this NGN case study. Nothing on screen says "STEMI". The case asks you to do what an experienced ED RN would do — read the cues, take the most dangerous possibility seriously, and move through the early protocol in the safe order.

What this case is testing

The case is built around an ST-elevation myocardial infarction presentation because it forces a full pass through the NCSBN Clinical Judgment Measurement Model on a time-sensitive cardiac emergency:

Recognize cues that change the working theory from "musculoskeletal chest pain" to "acute coronary syndrome" — the quality of the pain, the radiation pattern, the diaphoresis, the risk profile, and the ECG findings.
Analyze cues the way a cardiac-care nurse would — knowing how an inferior versus anterior pattern changes which vessel is likely involved and which complications you watch for.
Prioritize hypotheses when more than one differential could explain the picture — STEMI, unstable angina, aortic dissection, pulmonary embolism, pericarditis.
Generate solutions that match the door-to-balloon and door-to-needle clocks — IV access, antiplatelet therapy, oxygen criteria, pain control, and the cath-lab activation decision.
Take action in the order that protects the myocardium without skipping safety steps — the order of MONA elements is no longer rote, and the case will test whether you know why.
Evaluate outcomes after the first interventions using a fresh ECG, repeat troponin, pain score, and the client's own report.

Underneath the case you will touch several Client Needs categories at once: Safe and Effective Care Environment, Physiological Adaptation, Pharmacology and Parenteral Therapies (aspirin, P2Y12 inhibitors, anticoagulants, nitrates), Reduction of Risk Potential, and Health Promotion and Maintenance for the discharge teaching that closes the case.

Who this case is good for

This is a senior-level NCLEX-RN® case study. It is a strong fit for:

Senior nursing students preparing for NCLEX-RN® who have completed a med-surg or critical-care rotation.
Recent graduates working through NGN cases in the final stretch of a 30-, 60-, or 90-day NCLEX-RN® study plan.
Internationally educated nurses preparing for NCLEX-RN® who want practice with US chest-pain triage and the early-MI medication order set.
Anyone who memorised "MONA" without understanding why morphine is no longer first-line and why oxygen has criteria.

It is not the right first NGN case for a student who has only done multiple-choice questions so far. If that's you, start with the in-app NGN tutorial the first time you open any case — it walks the six clinical-judgment steps in plain language.

What you will work through, step by step

Inside the case you will move through six linked sub-items. Each ties to a single step in the CJMM clinical-judgment cycle and unlocks the next.

The opening sub-item asks you to highlight the cues that change the story from "indigestion" to "ACS". Picking too many cues is as wrong as picking too few.
The analyse sub-item asks you to match cues to a probable culprit vessel and complication risk. The wrong-but-tempting choices all sound clinically reasonable; the rationale walks you through the deciding feature.
A prioritisation sub-item asks you to rank the differentials by how dangerous they would be if missed, not by what feels most likely.
An action sub-item asks for the single first nursing action. Two of the choices look almost identical — separating them is the entire point of the item.
A handoff sub-item asks you to assemble a cath-lab activation report to the on-call cardiologist using building blocks instead of free text.
The closing sub-item asks you to evaluate the response after the first round of interventions using a fresh ECG, repeat troponin, and the client's own words.

Go deeper: For how to interpret ST-segment changes and connect ECG findings to urgent nursing actions, see the ECG/EKG interpretation guide.

At the end you will see your overall score, sub-item by sub-item feedback, and a short reflection prompt that feeds your Mistake DNA inside RN Clarity.

Why this case shows up in NCLEX-RN® prep so often

Acute MI is one of the most-tested presentations on the current NCLEX-RN® test plan because it rewards the reasoning the exam was designed to measure — multiple body systems, a time-sensitive medication plan, and a single ordered series of nursing actions where doing the right thing in the wrong order can hurt the client.

If you can think your way through this case calmly, you will have practised the same clinical-reasoning loop NCLEX-RN® test writers reward, on a presentation you are likely to see again the moment you start working as a nurse.

Try the full case

There is no spoiler here on purpose. An NGN case is about the reasoning you do while the screen is in front of you, not the answer key afterward. The case is open to free-preview members and full subscribers inside the RN Clarity NGN bank.

Try this case →

See also:

NCLEX-RN® Hub: Clinical Judgment Guide · NGN Case Studies Hub

Practice on RN Clarity: NGN Case Studies · Question Bank · Drug Cards