Saunders Comprehensive Review for the NCLEX-PN®
Examination
9th Edition
Cardiovascular (4)
1
A 62-year-old man arrives to the ED with sudden, crushing
substernal chest pain that began 40 minutes ago, diaphoresis,
and nausea. ECG shows ST-segment elevation in leads V2–V4.
Which is the nurse’s priority immediate action?
A. Prepare the client for immediate thrombolytic therapy.
B. Give 325 mg chewable aspirin PO (unless contraindicated).
C. Obtain a baseline troponin level.
D. Administer sublingual nitroglycerin.
Answer: B. Give 325 mg chewable aspirin PO (unless
contraindicated).
Rationale (correct): Aspirin administered immediately
(chewable, if possible) reduces platelet aggregation and early
mortality in suspected acute myocardial infarction (AMI) and is
considered the highest-priority initial action unless
contraindicated. It is rapid, bedside, and time-sensitive.
Rationale (incorrect):
A. Thrombolytic therapy may be indicated, but it requires
further assessment, contraindication screening, and
,preparation — aspirin is faster and immediately life-saving.
C. Troponin is diagnostic, but awaiting labs delays immediate
therapy that reduces mortality.
D. Sublingual nitroglycerin reduces ischemic pain and preload
but should follow administration of aspirin; nitroglycerin can
cause hypotension and is not the single highest-priority
immediate action.
Evidence-based principle: Administer chewable aspirin ASAP in
suspected AMI (unless allergic) as part of emergent care to
reduce mortality.
2
A client with chronic heart failure is taking furosemide daily.
Today the nurse notes muscle weakness and serum potassium
3.0 mEq/L (normal 3.5–5.0). Which action should the nurse take
first?
A. Administer IV potassium chloride push.
B. Obtain an ECG immediately.
C. Give the scheduled dose of furosemide.
D. Encourage the client to eat a banana.
Answer: B. Obtain an ECG immediately.
Rationale (correct): Serum K+ of 3.0 places the client at risk for
cardiac dysrhythmias. The priority is to assess cardiac
conduction for changes (peaked/flattened T waves, U waves,
PVCs). An ECG will rapidly show whether the hypokalemia is
,affecting cardiac rhythm and therefore guide urgency of
therapy.
Rationale (incorrect):
A. IV KCl push is unsafe — potassium must be administered
diluted and controlled (IV infusion), not as a push. Further,
immediate ECG assessment should precede emergent
replacement decisions.
C. Giving furosemide will worsen hypokalemia; the scheduled
dose should be held until assessed.
D. Encouraging dietary potassium is appropriate for mild
hypokalemia but is not the immediate action with a level of 3.0
and potential for conduction changes.
Evidence-based principle: Hypokalemia with ECG changes or
level <3.0–3.2 requires prompt cardiac monitoring and
controlled potassium replacement (never IV push).
3
A client with chronic atrial fibrillation is on warfarin. Today the
INR is reported 1.6 (therapeutic goal 2–3). The client asks why
the INR is low and what the nurse will do. Which explanation
and plan is best?
A. “Your INR is too low; I’ll hold warfarin today and order
vitamin K.”
B. “A low INR means less anticoagulation — we’ll contact the
provider about increasing the warfarin dose.”
, C. “Your INR is within therapeutic range; continue current
dosing.”
D. “You should stop taking all green leafy vegetables starting
today.”
Answer: B. “A low INR means less anticoagulation — we’ll
contact the provider about increasing the warfarin dose.”
Rationale (correct): An INR of 1.6 is below the typical
therapeutic range for atrial fibrillation (2–3), indicating
subtherapeutic anticoagulation and increased
thromboembolism risk. The appropriate nurse response is
patient education about what a low INR means and to notify
the provider to consider dose adjustment, while reinforcing
adherence and interactions.
Rationale (incorrect):
A. Holding warfarin and giving vitamin K would increase clotting
(raise INR downward effect) — inappropriate for a low INR.
C. INR 1.6 is not therapeutic for AF; continuing dosing without
notifying provider is unsafe.
D. Stopping leafy greens abruptly is unnecessary; diet education
should focus on maintaining consistent vitamin K intake rather
than eliminating foods.
Evidence-based principle: Warfarin management requires
maintaining INR within therapeutic range; nurses educate about
adherence, consistent vitamin K intake, drug interactions, and
report subtherapeutic INR for provider adjustment.
Examination
9th Edition
Cardiovascular (4)
1
A 62-year-old man arrives to the ED with sudden, crushing
substernal chest pain that began 40 minutes ago, diaphoresis,
and nausea. ECG shows ST-segment elevation in leads V2–V4.
Which is the nurse’s priority immediate action?
A. Prepare the client for immediate thrombolytic therapy.
B. Give 325 mg chewable aspirin PO (unless contraindicated).
C. Obtain a baseline troponin level.
D. Administer sublingual nitroglycerin.
Answer: B. Give 325 mg chewable aspirin PO (unless
contraindicated).
Rationale (correct): Aspirin administered immediately
(chewable, if possible) reduces platelet aggregation and early
mortality in suspected acute myocardial infarction (AMI) and is
considered the highest-priority initial action unless
contraindicated. It is rapid, bedside, and time-sensitive.
Rationale (incorrect):
A. Thrombolytic therapy may be indicated, but it requires
further assessment, contraindication screening, and
,preparation — aspirin is faster and immediately life-saving.
C. Troponin is diagnostic, but awaiting labs delays immediate
therapy that reduces mortality.
D. Sublingual nitroglycerin reduces ischemic pain and preload
but should follow administration of aspirin; nitroglycerin can
cause hypotension and is not the single highest-priority
immediate action.
Evidence-based principle: Administer chewable aspirin ASAP in
suspected AMI (unless allergic) as part of emergent care to
reduce mortality.
2
A client with chronic heart failure is taking furosemide daily.
Today the nurse notes muscle weakness and serum potassium
3.0 mEq/L (normal 3.5–5.0). Which action should the nurse take
first?
A. Administer IV potassium chloride push.
B. Obtain an ECG immediately.
C. Give the scheduled dose of furosemide.
D. Encourage the client to eat a banana.
Answer: B. Obtain an ECG immediately.
Rationale (correct): Serum K+ of 3.0 places the client at risk for
cardiac dysrhythmias. The priority is to assess cardiac
conduction for changes (peaked/flattened T waves, U waves,
PVCs). An ECG will rapidly show whether the hypokalemia is
,affecting cardiac rhythm and therefore guide urgency of
therapy.
Rationale (incorrect):
A. IV KCl push is unsafe — potassium must be administered
diluted and controlled (IV infusion), not as a push. Further,
immediate ECG assessment should precede emergent
replacement decisions.
C. Giving furosemide will worsen hypokalemia; the scheduled
dose should be held until assessed.
D. Encouraging dietary potassium is appropriate for mild
hypokalemia but is not the immediate action with a level of 3.0
and potential for conduction changes.
Evidence-based principle: Hypokalemia with ECG changes or
level <3.0–3.2 requires prompt cardiac monitoring and
controlled potassium replacement (never IV push).
3
A client with chronic atrial fibrillation is on warfarin. Today the
INR is reported 1.6 (therapeutic goal 2–3). The client asks why
the INR is low and what the nurse will do. Which explanation
and plan is best?
A. “Your INR is too low; I’ll hold warfarin today and order
vitamin K.”
B. “A low INR means less anticoagulation — we’ll contact the
provider about increasing the warfarin dose.”
, C. “Your INR is within therapeutic range; continue current
dosing.”
D. “You should stop taking all green leafy vegetables starting
today.”
Answer: B. “A low INR means less anticoagulation — we’ll
contact the provider about increasing the warfarin dose.”
Rationale (correct): An INR of 1.6 is below the typical
therapeutic range for atrial fibrillation (2–3), indicating
subtherapeutic anticoagulation and increased
thromboembolism risk. The appropriate nurse response is
patient education about what a low INR means and to notify
the provider to consider dose adjustment, while reinforcing
adherence and interactions.
Rationale (incorrect):
A. Holding warfarin and giving vitamin K would increase clotting
(raise INR downward effect) — inappropriate for a low INR.
C. INR 1.6 is not therapeutic for AF; continuing dosing without
notifying provider is unsafe.
D. Stopping leafy greens abruptly is unnecessary; diet education
should focus on maintaining consistent vitamin K intake rather
than eliminating foods.
Evidence-based principle: Warfarin management requires
maintaining INR within therapeutic range; nurses educate about
adherence, consistent vitamin K intake, drug interactions, and
report subtherapeutic INR for provider adjustment.
