Saunders Comprehensive Review for the NCLEX-PN®
Examination
9th Edition
Author(s)Linda Anne Silvestri; Angela Silvestri
TEST BANK
Test-bank style items — Medical-Surgical Nursing
(Cardiovascular, Respiratory, Neurological, GI,
Renal, Endocrine, Musculoskeletal)
Item 1 — Cardiovascular (heart failure,
pathophysiology & intervention)
A 68-year-old client with chronic systolic heart
failure (EF 28%) reports increasing shortness of
breath and pitting edema. Which nursing action is
the highest priority?
,A. Encourage a high-protein diet to improve muscle
strength.
B. Place the client in high-Fowler’s position and
administer prescribed oxygen.
C. Obtain a 12-lead ECG to evaluate for ischemia.
D. Teach the client to limit daily fluid intake to 1 L.
Correct answer: B
Rationale (correct): In acute decompensated heart
failure with dyspnea and edema, the immediate
priority is to improve oxygenation and reduce work
of breathing — high-Fowler’s position plus
supplemental oxygen (per provider orders)
addresses respiratory compromise first
(airway/oxygenation is prioritized).
Why others are incorrect: A (high-protein diet) is
not immediate priority and does not rapidly relieve
dyspnea. C (ECG) may be important if ischemia is
suspected but is secondary to stabilizing
airway/oxygenation. D (fluid restriction teaching) is
important for long-term management but not the
,immediate priority when respiratory distress is
present.
Item 2 — Cardiovascular (post-MI labs & meds)
A client is admitted 12 hours after an ST-elevation
MI. Which lab result most directly indicates ongoing
myocardial injury and how should the nurse
interpret it?
A. Troponin I elevated and rising — suggests
ongoing myocardial necrosis.
B. CK-MB within normal limits — rules out cardiac
muscle injury.
C. BNP elevated — indicates acute MI severity.
D. Serum potassium 3.2 mEq/L — indicates
myocardial damage.
Correct answer: A
Rationale (correct): Troponin I is the most specific
marker for myocardial necrosis; an elevated and
rising troponin after MI indicates ongoing injury or
extension of infarction and requires prompt clinical
evaluation.
, Why others are incorrect: B: CK-MB may be normal
early or in small infarcts; a normal CK-MB does not
rule out MI. C: BNP is a marker of heart
failure/stretch, not specific for acute MI severity. D:
Hypokalemia can predispose to dysrhythmias but
does not itself indicate myocardial necrosis.
Item 3 — Respiratory (COPD exacerbation; ABG
interpretation)
An older adult with COPD is admitted with an
exacerbation. Arterial blood gas: pH 7.32, PaCO₂ 58
mm Hg, HCO₃⁻ 29 mEq/L. What is the best
interpretation?
A. Metabolic acidosis uncompensated.
B. Acute respiratory acidosis with metabolic
compensation.
C. Chronic metabolic alkalosis.
D. Respiratory alkalosis with partial compensation.
Correct answer: B
Rationale (correct): pH low (acidosis) with elevated
PaCO₂ indicates respiratory acidosis. HCO₃⁻ is
Examination
9th Edition
Author(s)Linda Anne Silvestri; Angela Silvestri
TEST BANK
Test-bank style items — Medical-Surgical Nursing
(Cardiovascular, Respiratory, Neurological, GI,
Renal, Endocrine, Musculoskeletal)
Item 1 — Cardiovascular (heart failure,
pathophysiology & intervention)
A 68-year-old client with chronic systolic heart
failure (EF 28%) reports increasing shortness of
breath and pitting edema. Which nursing action is
the highest priority?
,A. Encourage a high-protein diet to improve muscle
strength.
B. Place the client in high-Fowler’s position and
administer prescribed oxygen.
C. Obtain a 12-lead ECG to evaluate for ischemia.
D. Teach the client to limit daily fluid intake to 1 L.
Correct answer: B
Rationale (correct): In acute decompensated heart
failure with dyspnea and edema, the immediate
priority is to improve oxygenation and reduce work
of breathing — high-Fowler’s position plus
supplemental oxygen (per provider orders)
addresses respiratory compromise first
(airway/oxygenation is prioritized).
Why others are incorrect: A (high-protein diet) is
not immediate priority and does not rapidly relieve
dyspnea. C (ECG) may be important if ischemia is
suspected but is secondary to stabilizing
airway/oxygenation. D (fluid restriction teaching) is
important for long-term management but not the
,immediate priority when respiratory distress is
present.
Item 2 — Cardiovascular (post-MI labs & meds)
A client is admitted 12 hours after an ST-elevation
MI. Which lab result most directly indicates ongoing
myocardial injury and how should the nurse
interpret it?
A. Troponin I elevated and rising — suggests
ongoing myocardial necrosis.
B. CK-MB within normal limits — rules out cardiac
muscle injury.
C. BNP elevated — indicates acute MI severity.
D. Serum potassium 3.2 mEq/L — indicates
myocardial damage.
Correct answer: A
Rationale (correct): Troponin I is the most specific
marker for myocardial necrosis; an elevated and
rising troponin after MI indicates ongoing injury or
extension of infarction and requires prompt clinical
evaluation.
, Why others are incorrect: B: CK-MB may be normal
early or in small infarcts; a normal CK-MB does not
rule out MI. C: BNP is a marker of heart
failure/stretch, not specific for acute MI severity. D:
Hypokalemia can predispose to dysrhythmias but
does not itself indicate myocardial necrosis.
Item 3 — Respiratory (COPD exacerbation; ABG
interpretation)
An older adult with COPD is admitted with an
exacerbation. Arterial blood gas: pH 7.32, PaCO₂ 58
mm Hg, HCO₃⁻ 29 mEq/L. What is the best
interpretation?
A. Metabolic acidosis uncompensated.
B. Acute respiratory acidosis with metabolic
compensation.
C. Chronic metabolic alkalosis.
D. Respiratory alkalosis with partial compensation.
Correct answer: B
Rationale (correct): pH low (acidosis) with elevated
PaCO₂ indicates respiratory acidosis. HCO₃⁻ is
