Saunders Comprehensive Review for the NCLEX-PN®
Examination
9th Edition
1. A 68-year-old man is admitted with acute decompensated
heart failure (HF). He has jugular venous distention, bilateral
crackles, and 2+ pitting edema of both legs. Which nursing
action has the highest immediate priority?
A. Administer intravenous furosemide as ordered.
B. Encourage the patient to ambulate in the hall.
C. Begin a low-sodium nutrition teaching plan.
D. Obtain a morning weight.
Correct answer: A. Administer intravenous furosemide as
ordered.
Rationale:
• Why A is correct: The patient shows signs of volume
overload and pulmonary congestion; IV loop diuretics (e.g.,
furosemide) produce rapid diuresis, reduce preload,
relieve pulmonary edema, and improve oxygenation —
making this the highest immediate priority. Management
of acute decompensated HF prioritizes rapid relief of
congestion. (Evidence-based HF guidelines support diuretic
use for volume overload.) AHA Journals
, • Why B is incorrect: Ambulation would increase metabolic
demand and is contraindicated until congestion and
oxygenation are stabilized.
• Why C is incorrect: Dietary teaching is important but not
an immediate action for acute respiratory compromise.
• Why D is incorrect: Daily weight is useful for ongoing
monitoring but is not the highest immediate priority
compared with rapidly decreasing intravascular volume
causing pulmonary edema.
2. A patient with newly diagnosed atrial fibrillation (AF) is
admitted. The primary healthcare provider prescribes diltiazem
(calcium channel blocker). The nurse should prioritize
monitoring which of the following?
A. Serum potassium level.
B. Heart rate and blood pressure.
C. Serum creatinine.
D. Oxygen saturation by pulse oximetry.
Correct answer: B. Heart rate and blood pressure.
Rationale:
• Why B is correct: Diltiazem slows AV nodal conduction and
can cause bradycardia and hypotension; continuous
monitoring of heart rate and blood pressure is essential
after administration. Nursing priority is to detect
, hemodynamic instability and withhold dose or notify
provider if bradycardia or hypotension occurs.
• Why A is incorrect: Potassium monitoring is more relevant
to some antiarrhythmics (e.g., digoxin toxicity risk with
hypokalemia) but not the immediate priority for diltiazem.
• Why C is incorrect: Creatinine monitoring is relevant with
drugs renally cleared; diltiazem is primarily hepatically
metabolized.
• Why D is incorrect: Oxygen saturation is important with
cardiopulmonary compromise but not the primary
parameter altered by diltiazem.
3. A client with chronic stable angina asks how nitroglycerin
sublingual tablets work to relieve chest pain. The nurse explains
the primary mechanism is:
A. Decreasing myocardial oxygen demand by systemic
vasodilation.
B. Increasing coronary artery atherosclerotic plaque stability.
C. Increasing heart rate and contractility.
D. Blocking beta-adrenergic receptors to reduce workload.
Correct answer: A. Decreasing myocardial oxygen demand by
systemic vasodilation.
Rationale:
, • Why A is correct: Nitroglycerin produces venous and some
arterial dilation, decreasing preload and myocardial wall
tension, thus lowering myocardial oxygen demand and
relieving ischemic pain. It also dilates coronary arteries to
some extent.
• Why B is incorrect: Nitroglycerin does not alter plaque
stability. Statins and lifestyle affect plaque.
• Why C is incorrect: Nitroglycerin typically causes reflex
tachycardia only as a side effect; increasing heart
rate/contractility would worsen ischemia.
• Why D is incorrect: Beta-blockers block beta receptors;
nitroglycerin is a nitrate, not a beta-blocker.
4. Lab results for a patient on warfarin therapy show an INR of
6.0 (therapeutic goal 2.0–3.0). The patient reports no bleeding.
Which action should the nurse take first?
A. Hold the next warfarin dose and notify the prescriber.
B. Administer vitamin K per standing protocol immediately.
C. Send the patient for urgent diagnostic imaging.
D. Document the result and continue warfarin as prescribed.
Correct answer: A. Hold the next warfarin dose and notify the
prescriber.
Rationale:
Examination
9th Edition
1. A 68-year-old man is admitted with acute decompensated
heart failure (HF). He has jugular venous distention, bilateral
crackles, and 2+ pitting edema of both legs. Which nursing
action has the highest immediate priority?
A. Administer intravenous furosemide as ordered.
B. Encourage the patient to ambulate in the hall.
C. Begin a low-sodium nutrition teaching plan.
D. Obtain a morning weight.
Correct answer: A. Administer intravenous furosemide as
ordered.
Rationale:
• Why A is correct: The patient shows signs of volume
overload and pulmonary congestion; IV loop diuretics (e.g.,
furosemide) produce rapid diuresis, reduce preload,
relieve pulmonary edema, and improve oxygenation —
making this the highest immediate priority. Management
of acute decompensated HF prioritizes rapid relief of
congestion. (Evidence-based HF guidelines support diuretic
use for volume overload.) AHA Journals
, • Why B is incorrect: Ambulation would increase metabolic
demand and is contraindicated until congestion and
oxygenation are stabilized.
• Why C is incorrect: Dietary teaching is important but not
an immediate action for acute respiratory compromise.
• Why D is incorrect: Daily weight is useful for ongoing
monitoring but is not the highest immediate priority
compared with rapidly decreasing intravascular volume
causing pulmonary edema.
2. A patient with newly diagnosed atrial fibrillation (AF) is
admitted. The primary healthcare provider prescribes diltiazem
(calcium channel blocker). The nurse should prioritize
monitoring which of the following?
A. Serum potassium level.
B. Heart rate and blood pressure.
C. Serum creatinine.
D. Oxygen saturation by pulse oximetry.
Correct answer: B. Heart rate and blood pressure.
Rationale:
• Why B is correct: Diltiazem slows AV nodal conduction and
can cause bradycardia and hypotension; continuous
monitoring of heart rate and blood pressure is essential
after administration. Nursing priority is to detect
, hemodynamic instability and withhold dose or notify
provider if bradycardia or hypotension occurs.
• Why A is incorrect: Potassium monitoring is more relevant
to some antiarrhythmics (e.g., digoxin toxicity risk with
hypokalemia) but not the immediate priority for diltiazem.
• Why C is incorrect: Creatinine monitoring is relevant with
drugs renally cleared; diltiazem is primarily hepatically
metabolized.
• Why D is incorrect: Oxygen saturation is important with
cardiopulmonary compromise but not the primary
parameter altered by diltiazem.
3. A client with chronic stable angina asks how nitroglycerin
sublingual tablets work to relieve chest pain. The nurse explains
the primary mechanism is:
A. Decreasing myocardial oxygen demand by systemic
vasodilation.
B. Increasing coronary artery atherosclerotic plaque stability.
C. Increasing heart rate and contractility.
D. Blocking beta-adrenergic receptors to reduce workload.
Correct answer: A. Decreasing myocardial oxygen demand by
systemic vasodilation.
Rationale:
, • Why A is correct: Nitroglycerin produces venous and some
arterial dilation, decreasing preload and myocardial wall
tension, thus lowering myocardial oxygen demand and
relieving ischemic pain. It also dilates coronary arteries to
some extent.
• Why B is incorrect: Nitroglycerin does not alter plaque
stability. Statins and lifestyle affect plaque.
• Why C is incorrect: Nitroglycerin typically causes reflex
tachycardia only as a side effect; increasing heart
rate/contractility would worsen ischemia.
• Why D is incorrect: Beta-blockers block beta receptors;
nitroglycerin is a nitrate, not a beta-blocker.
4. Lab results for a patient on warfarin therapy show an INR of
6.0 (therapeutic goal 2.0–3.0). The patient reports no bleeding.
Which action should the nurse take first?
A. Hold the next warfarin dose and notify the prescriber.
B. Administer vitamin K per standing protocol immediately.
C. Send the patient for urgent diagnostic imaging.
D. Document the result and continue warfarin as prescribed.
Correct answer: A. Hold the next warfarin dose and notify the
prescriber.
Rationale:
