Saunders Comprehensive Review for the NCLEX-PN®
Examination
9th Edition
1
System: Cardiovascular — Acute Coronary Syndrome
Client Need: Physiological Integrity — Physiological Adaptation
Cognitive Level: Analyze
A 62-year-old man arrives at the ED with 90 minutes of chest
pressure and diaphoresis. ECG shows ST-segment elevation in
leads II, III, and aVF. He is hemodynamically stable. Which
nursing action is the highest priority?
A. Prepare the client for immediate percutaneous coronary
intervention (PCI).
B. Administer sublingual nitroglycerin and reassess pain.
C. Give chewable aspirin 325 mg and document allergy status.
D. Start a continuous IV heparin infusion.
Answer: A
Rationale — Correct (A): Inferior-lead ST-elevation myocardial
infarction (STEMI) requires timely reperfusion to limit
myocardial damage. Current evidence and guidelines prioritize
primary PCI as the preferred reperfusion strategy if it can be
performed quickly (door-to-balloon within guideline
timeframes). As the nurse, preparing the client for immediate
,PCI (consent verification, IV access, NPO status, pre-procedural
meds per protocol, continuous monitoring) is highest priority to
restore coronary perfusion and reduce mortality.
Rationale — Incorrect:
• B. Nitroglycerin may relieve ischemic pain and improve
coronary perfusion but is not the highest priority ahead of
definitive reperfusion in a STEMI candidate for PCI. It is
appropriate after assessing for contraindications (e.g.,
recent phosphodiesterase inhibitor use, hypotension).
• C. Aspirin is essential early therapy for ACS (chewable 162–
325 mg) and should be given promptly, but in this scenario
preparing for PCI that will revascularize the occluded
artery is prioritized. Aspirin can be given concurrently.
• D. Heparin may be indicated as adjunctive therapy but
starting an IV heparin infusion is not as immediately
priority as activating the cath lab for PCI in a STEMI.
2
System: Cardiovascular — Heart Failure
Client Need: Physiological Integrity — Reduction of Risk
Potential
Cognitive Level: Apply
A client with chronic systolic heart failure (EF 30%) is admitted
with worsening dyspnea and 3+ pitting edema. The provider
,prescribes IV furosemide 40 mg now and daily weights. Which
assessment finding should the nurse monitor most closely after
administering the IV diuretic?
A. Serum sodium level.
B. Urine output and serum potassium level.
C. Presence of jugular venous distention (JVD).
D. Blood glucose level.
Answer: B
Rationale — Correct (B): Loop diuretics like furosemide can
cause significant diuresis leading to hypovolemia and
potassium loss. Monitoring urine output evaluates therapeutic
effect (diuresis) and risk for acute kidney injury; serum
potassium is important because hypokalemia increases
arrhythmia risk in heart failure patients (and with concurrent
digoxin use). Evidence-based nursing includes close monitoring
of intake/output and electrolytes after IV diuresis.
Rationale — Incorrect:
• A. Serum sodium is important but potassium and urine
output are more immediately affected by loop diuretics
and more critical for acute monitoring.
• C. JVD is a useful sign of volume status but changes will be
slower; immediate urine output and electrolytes provide
more direct, rapid data post-diuretic.
, • D. Blood glucose is not the most relevant immediate
parameter after IV furosemide unless the client has
diabetes; potassium and output are primary.
3
System: Cardiovascular — Dysrhythmia/Pharmacology
Client Need: Safe, Effective Care Environment — Management
of Care
Cognitive Level: Apply
A client with atrial fibrillation is started on warfarin. Which
statement by the client indicates understanding of warfarin
teaching?
A. “I will take extra vitamin K on days I feel like bleeding.”
B. “I will use an electric razor and avoid aspirin.”
C. “I should stop taking warfarin if my teeth bleed.”
D. “I will keep my INR between 1.0–1.5.”
Answer: B
Rationale — Correct (B): Warfarin increases bleeding risk;
patient education should include bleeding precautions (use an
electric razor, soft-bristle toothbrush, avoid NSAIDs/aspirin
unless prescribed) and the need for regular INR monitoring.
Avoiding aspirin reduces additive antiplatelet bleeding risk.
Rationale — Incorrect:
Examination
9th Edition
1
System: Cardiovascular — Acute Coronary Syndrome
Client Need: Physiological Integrity — Physiological Adaptation
Cognitive Level: Analyze
A 62-year-old man arrives at the ED with 90 minutes of chest
pressure and diaphoresis. ECG shows ST-segment elevation in
leads II, III, and aVF. He is hemodynamically stable. Which
nursing action is the highest priority?
A. Prepare the client for immediate percutaneous coronary
intervention (PCI).
B. Administer sublingual nitroglycerin and reassess pain.
C. Give chewable aspirin 325 mg and document allergy status.
D. Start a continuous IV heparin infusion.
Answer: A
Rationale — Correct (A): Inferior-lead ST-elevation myocardial
infarction (STEMI) requires timely reperfusion to limit
myocardial damage. Current evidence and guidelines prioritize
primary PCI as the preferred reperfusion strategy if it can be
performed quickly (door-to-balloon within guideline
timeframes). As the nurse, preparing the client for immediate
,PCI (consent verification, IV access, NPO status, pre-procedural
meds per protocol, continuous monitoring) is highest priority to
restore coronary perfusion and reduce mortality.
Rationale — Incorrect:
• B. Nitroglycerin may relieve ischemic pain and improve
coronary perfusion but is not the highest priority ahead of
definitive reperfusion in a STEMI candidate for PCI. It is
appropriate after assessing for contraindications (e.g.,
recent phosphodiesterase inhibitor use, hypotension).
• C. Aspirin is essential early therapy for ACS (chewable 162–
325 mg) and should be given promptly, but in this scenario
preparing for PCI that will revascularize the occluded
artery is prioritized. Aspirin can be given concurrently.
• D. Heparin may be indicated as adjunctive therapy but
starting an IV heparin infusion is not as immediately
priority as activating the cath lab for PCI in a STEMI.
2
System: Cardiovascular — Heart Failure
Client Need: Physiological Integrity — Reduction of Risk
Potential
Cognitive Level: Apply
A client with chronic systolic heart failure (EF 30%) is admitted
with worsening dyspnea and 3+ pitting edema. The provider
,prescribes IV furosemide 40 mg now and daily weights. Which
assessment finding should the nurse monitor most closely after
administering the IV diuretic?
A. Serum sodium level.
B. Urine output and serum potassium level.
C. Presence of jugular venous distention (JVD).
D. Blood glucose level.
Answer: B
Rationale — Correct (B): Loop diuretics like furosemide can
cause significant diuresis leading to hypovolemia and
potassium loss. Monitoring urine output evaluates therapeutic
effect (diuresis) and risk for acute kidney injury; serum
potassium is important because hypokalemia increases
arrhythmia risk in heart failure patients (and with concurrent
digoxin use). Evidence-based nursing includes close monitoring
of intake/output and electrolytes after IV diuresis.
Rationale — Incorrect:
• A. Serum sodium is important but potassium and urine
output are more immediately affected by loop diuretics
and more critical for acute monitoring.
• C. JVD is a useful sign of volume status but changes will be
slower; immediate urine output and electrolytes provide
more direct, rapid data post-diuretic.
, • D. Blood glucose is not the most relevant immediate
parameter after IV furosemide unless the client has
diabetes; potassium and output are primary.
3
System: Cardiovascular — Dysrhythmia/Pharmacology
Client Need: Safe, Effective Care Environment — Management
of Care
Cognitive Level: Apply
A client with atrial fibrillation is started on warfarin. Which
statement by the client indicates understanding of warfarin
teaching?
A. “I will take extra vitamin K on days I feel like bleeding.”
B. “I will use an electric razor and avoid aspirin.”
C. “I should stop taking warfarin if my teeth bleed.”
D. “I will keep my INR between 1.0–1.5.”
Answer: B
Rationale — Correct (B): Warfarin increases bleeding risk;
patient education should include bleeding precautions (use an
electric razor, soft-bristle toothbrush, avoid NSAIDs/aspirin
unless prescribed) and the need for regular INR monitoring.
Avoiding aspirin reduces additive antiplatelet bleeding risk.
Rationale — Incorrect:
