Saunders Comprehensive Review for the NCLEX-PN®
Examination
9th Edition
1 — Cardiovascular: Acute MI — Priority Intervention
A 62-year-old man is admitted with chest pressure radiating to
his left arm and jaw for 45 minutes. ECG shows ST-segment
elevation in leads II, III, and aVF. Blood pressure 90/56 mm Hg,
HR 110 bpm, respiratory rate 20/min, SpO₂ 96% on room air.
Which nursing action is the highest priority?
A. Administer aspirin 325 mg chewable per protocol.
B. Obtain blood for troponin and basic metabolic panel.
C. Prepare the client for emergent percutaneous coronary
intervention (PCI).
D. Give sublingual nitroglycerin.
Answer: A. Administer aspirin 325 mg chewable per protocol.
Rationale (correct): Chewable aspirin should be given
immediately in suspected acute myocardial infarction (AMI)
unless contraindicated — it inhibits platelet aggregation and
reduces early mortality. Immediate antiplatelet therapy is a
time-sensitive, evidence-based priority in STEMI care.
Rationale (incorrect):
B — Obtaining labs is important but not the single highest
priority; it should occur concurrently but after/while
,administering aspirin.
C — Preparing for PCI is essential for STEMI reperfusion, but the
nurse can and should give aspirin immediately while arranging
PCI. Timely aspirin administration is quicker and life-saving.
D — Sublingual nitroglycerin may relieve ischemic pain and
reduce preload, but it can worsen hypotension (BP 90/56); thus
nitroglycerin is contraindicated until BP stabilizes.
2 — Cardiovascular: Heart Failure — Lab Interpretation &
Teaching
A 74-year-old woman with chronic heart failure (HF) presents
with increasing dyspnea and ankle swelling. Her serum B-type
natriuretic peptide (BNP) is 980 pg/mL (normal <100),
creatinine 1.1 mg/dL, potassium 4.5 mEq/L. Which statement
by the nurse best explains the BNP result and next steps?
A. “A BNP of 980 confirms fluid overload from HF; we will likely
increase your diuretic and monitor your weight and
electrolytes.”
B. “This BNP is normal; it rules out heart failure as the cause of
your symptoms.”
C. “BNP only reflects kidney function, so we’ll consult
nephrology instead of changing your HF medications.”
D. “A high BNP means your ejection fraction is normal; no
changes are needed.”
,Answer: A. “A BNP of 980 confirms fluid overload from HF; we
will likely increase your diuretic and monitor your weight and
electrolytes.”
Rationale (correct): Elevated BNP correlates with ventricular
stretch and is commonly used to support HF diagnosis and
assess severity. A value of 980 is consistent with
decompensated HF. Diuretic adjustment and close monitoring
of weight, urine output, and electrolytes (K⁺, creatinine) are
evidence-based interventions.
Rationale (incorrect):
B — BNP 980 is markedly elevated and does not rule out HF; it
supports it.
C — BNP is influenced by both cardiac and renal function but
primarily indicates cardiac ventricular stress; nephrology
referral may be needed if renal issues arise, but primary HF
management is indicated.
D — BNP does not indicate ejection fraction being normal; high
BNP usually suggests volume/pressure overload and warrants
treatment.
3 — Cardiovascular: Anticoagulation Education
A client with new atrial fibrillation is prescribed warfarin. Which
statement by the client indicates correct understanding of
discharge teaching?
, A. “I’ll keep my vitamin K intake consistent and have regular INR
checks.”
B. “I’ll stop taking warfarin before dental cleanings without
telling anyone.”
C. “I can take aspirin on my own whenever I have a headache.”
D. “I don’t need to report any increased bruising; it’s normal.”
Answer: A. “I’ll keep my vitamin K intake consistent and have
regular INR checks.”
Rationale (correct): Warfarin’s effect is influenced by dietary
vitamin K; consistent intake and regular INR monitoring are
essential to maintain therapeutic anticoagulation and reduce
risk of bleeding or thrombosis.
Rationale (incorrect):
B — Stopping warfarin without provider guidance risks
thrombosis; dental procedures may require coordinated
management.
C — Adding aspirin increases bleeding risk; the client should
consult the prescriber before taking antiplatelets.
D — Increased bruising could indicate over-anticoagulation; the
client must report bleeding signs promptly.
4 — Cardiovascular: Post-Op CABG Priority Assessment
A client returns to the post-anesthesia care unit after coronary
artery bypass grafting (CABG). Which assessment finding
requires immediate intervention?
Examination
9th Edition
1 — Cardiovascular: Acute MI — Priority Intervention
A 62-year-old man is admitted with chest pressure radiating to
his left arm and jaw for 45 minutes. ECG shows ST-segment
elevation in leads II, III, and aVF. Blood pressure 90/56 mm Hg,
HR 110 bpm, respiratory rate 20/min, SpO₂ 96% on room air.
Which nursing action is the highest priority?
A. Administer aspirin 325 mg chewable per protocol.
B. Obtain blood for troponin and basic metabolic panel.
C. Prepare the client for emergent percutaneous coronary
intervention (PCI).
D. Give sublingual nitroglycerin.
Answer: A. Administer aspirin 325 mg chewable per protocol.
Rationale (correct): Chewable aspirin should be given
immediately in suspected acute myocardial infarction (AMI)
unless contraindicated — it inhibits platelet aggregation and
reduces early mortality. Immediate antiplatelet therapy is a
time-sensitive, evidence-based priority in STEMI care.
Rationale (incorrect):
B — Obtaining labs is important but not the single highest
priority; it should occur concurrently but after/while
,administering aspirin.
C — Preparing for PCI is essential for STEMI reperfusion, but the
nurse can and should give aspirin immediately while arranging
PCI. Timely aspirin administration is quicker and life-saving.
D — Sublingual nitroglycerin may relieve ischemic pain and
reduce preload, but it can worsen hypotension (BP 90/56); thus
nitroglycerin is contraindicated until BP stabilizes.
2 — Cardiovascular: Heart Failure — Lab Interpretation &
Teaching
A 74-year-old woman with chronic heart failure (HF) presents
with increasing dyspnea and ankle swelling. Her serum B-type
natriuretic peptide (BNP) is 980 pg/mL (normal <100),
creatinine 1.1 mg/dL, potassium 4.5 mEq/L. Which statement
by the nurse best explains the BNP result and next steps?
A. “A BNP of 980 confirms fluid overload from HF; we will likely
increase your diuretic and monitor your weight and
electrolytes.”
B. “This BNP is normal; it rules out heart failure as the cause of
your symptoms.”
C. “BNP only reflects kidney function, so we’ll consult
nephrology instead of changing your HF medications.”
D. “A high BNP means your ejection fraction is normal; no
changes are needed.”
,Answer: A. “A BNP of 980 confirms fluid overload from HF; we
will likely increase your diuretic and monitor your weight and
electrolytes.”
Rationale (correct): Elevated BNP correlates with ventricular
stretch and is commonly used to support HF diagnosis and
assess severity. A value of 980 is consistent with
decompensated HF. Diuretic adjustment and close monitoring
of weight, urine output, and electrolytes (K⁺, creatinine) are
evidence-based interventions.
Rationale (incorrect):
B — BNP 980 is markedly elevated and does not rule out HF; it
supports it.
C — BNP is influenced by both cardiac and renal function but
primarily indicates cardiac ventricular stress; nephrology
referral may be needed if renal issues arise, but primary HF
management is indicated.
D — BNP does not indicate ejection fraction being normal; high
BNP usually suggests volume/pressure overload and warrants
treatment.
3 — Cardiovascular: Anticoagulation Education
A client with new atrial fibrillation is prescribed warfarin. Which
statement by the client indicates correct understanding of
discharge teaching?
, A. “I’ll keep my vitamin K intake consistent and have regular INR
checks.”
B. “I’ll stop taking warfarin before dental cleanings without
telling anyone.”
C. “I can take aspirin on my own whenever I have a headache.”
D. “I don’t need to report any increased bruising; it’s normal.”
Answer: A. “I’ll keep my vitamin K intake consistent and have
regular INR checks.”
Rationale (correct): Warfarin’s effect is influenced by dietary
vitamin K; consistent intake and regular INR monitoring are
essential to maintain therapeutic anticoagulation and reduce
risk of bleeding or thrombosis.
Rationale (incorrect):
B — Stopping warfarin without provider guidance risks
thrombosis; dental procedures may require coordinated
management.
C — Adding aspirin increases bleeding risk; the client should
consult the prescriber before taking antiplatelets.
D — Increased bruising could indicate over-anticoagulation; the
client must report bleeding signs promptly.
4 — Cardiovascular: Post-Op CABG Priority Assessment
A client returns to the post-anesthesia care unit after coronary
artery bypass grafting (CABG). Which assessment finding
requires immediate intervention?
