Saunders Comprehensive Review for the NCLEX-PN®
Examination
9th Edition
Item 1 — Cardiovascular (Acute MI — immediate actions)
A 59-year-old man arrives at the ED with sudden crushing chest
pain radiating to his jaw. He is diaphoretic and anxious. ECG
shows ST-segment elevations in leads II, III, and aVF. Which
nursing action is the highest priority immediately on arrival?
A. Prepare the patient for emergent percutaneous coronary
intervention (PCI).
B. Give chewable aspirin 325 mg to the patient now (if not
already given).
C. Administer sublingual nitroglycerin for pain.
D. Obtain a complete metabolic panel and cardiac enzymes.
Correct answer: B
Rationale:
• Correct (B): Chewing 325 mg aspirin immediately inhibits
platelet aggregation and is a time-sensitive, evidence-
based first step in suspected acute myocardial infarction
(unless contraindicated by allergy). It reduces early
mortality and is an immediate pharmacologic priority
, while arranging reperfusion. (AHA/American guidelines
emphasize early antiplatelet therapy.) cpr.heart.org
• Why A is incorrect: Preparing for PCI is essential but takes
time and coordination; giving aspirin is a faster life-saving
intervention that should occur immediately.
• Why C is incorrect: Nitroglycerin can relieve ischemic pain
but should be withheld if there’s hypotension, recent
phosphodiesterase inhibitor use, or right ventricular MI; it
is not the single highest immediate priority over aspirin.
• Why D is incorrect: Labs and enzymes are important for
diagnosis and management but should not delay
immediate aspirin administration and interventions to
restore perfusion.
Item 2 — Cardiovascular (Heart failure — acute exacerbation)
A patient with chronic heart failure presents with worsening
dyspnea, bibasilar crackles, orthopnea, and prominent jugular
venous distention. BNP is markedly elevated. Which action
should the nurse perform first?
A. Administer IV loop diuretic as ordered.
B. Educate the patient about low-sodium diet.
C. Obtain a 12-lead ECG.
D. Ambulate the patient to improve ventilation.
Correct answer: A
,Rationale:
• Correct (A): In acute decompensated heart failure with
volume overload and pulmonary edema, prompt IV loop
diuretics reduce preload and relieve pulmonary congestion
— this is the priority to stabilize oxygenation and
perfusion. BNP elevation supports volume
overload/ventricular strain.
• Why B is incorrect: Patient education is important for long-
term management but not the first action during an acute
exacerbation.
• Why C is incorrect: ECG may be useful to evaluate
ischemia/arrhythmia, but immediate removal of excess
fluid (diuresis) to improve respiratory status is higher
priority.
• Why D is incorrect: Ambulation could worsen pulmonary
edema and is contraindicated during acute fluid overload.
Item 3 — Cardiovascular/Pharmacology (Warfarin
management)
A patient receiving warfarin therapy has an INR of 4.2 and
reports minor epistaxis (small nosebleed). He is
hemodynamically stable and has no major bleeding. Which is
the best initial nursing action?
, A. Continue the current warfarin dose and recheck INR in 1
week.
B. Hold the next warfarin dose and notify the prescriber for
possible oral vitamin K.
C. Administer IV vitamin K now.
D. Call for immediate prothrombin complex concentrate (PCC).
Correct answer: B
Rationale:
• Correct (B): For INR >4.0 with minor bleeding, best
practice commonly includes holding warfarin and
consulting prescriber. Low-dose oral vitamin K may be
advised depending on INR and bleeding. IV vitamin K or
PCC is reserved for serious or life-threatening bleeding.
This approach balances bleeding risk and thrombotic
protection.
• Why A is incorrect: Leaving the dose unchanged with INR
4.2 and active bleeding is unsafe.
• Why C is incorrect: IV vitamin K is used for major bleeding
or very high INR; it carries higher risk (and acts faster) but
is not first choice for minor bleeding.
• Why D is incorrect: PCC is for life-threatening hemorrhage
with urgent reversal needed; not indicated for minor
nosebleed.
Examination
9th Edition
Item 1 — Cardiovascular (Acute MI — immediate actions)
A 59-year-old man arrives at the ED with sudden crushing chest
pain radiating to his jaw. He is diaphoretic and anxious. ECG
shows ST-segment elevations in leads II, III, and aVF. Which
nursing action is the highest priority immediately on arrival?
A. Prepare the patient for emergent percutaneous coronary
intervention (PCI).
B. Give chewable aspirin 325 mg to the patient now (if not
already given).
C. Administer sublingual nitroglycerin for pain.
D. Obtain a complete metabolic panel and cardiac enzymes.
Correct answer: B
Rationale:
• Correct (B): Chewing 325 mg aspirin immediately inhibits
platelet aggregation and is a time-sensitive, evidence-
based first step in suspected acute myocardial infarction
(unless contraindicated by allergy). It reduces early
mortality and is an immediate pharmacologic priority
, while arranging reperfusion. (AHA/American guidelines
emphasize early antiplatelet therapy.) cpr.heart.org
• Why A is incorrect: Preparing for PCI is essential but takes
time and coordination; giving aspirin is a faster life-saving
intervention that should occur immediately.
• Why C is incorrect: Nitroglycerin can relieve ischemic pain
but should be withheld if there’s hypotension, recent
phosphodiesterase inhibitor use, or right ventricular MI; it
is not the single highest immediate priority over aspirin.
• Why D is incorrect: Labs and enzymes are important for
diagnosis and management but should not delay
immediate aspirin administration and interventions to
restore perfusion.
Item 2 — Cardiovascular (Heart failure — acute exacerbation)
A patient with chronic heart failure presents with worsening
dyspnea, bibasilar crackles, orthopnea, and prominent jugular
venous distention. BNP is markedly elevated. Which action
should the nurse perform first?
A. Administer IV loop diuretic as ordered.
B. Educate the patient about low-sodium diet.
C. Obtain a 12-lead ECG.
D. Ambulate the patient to improve ventilation.
Correct answer: A
,Rationale:
• Correct (A): In acute decompensated heart failure with
volume overload and pulmonary edema, prompt IV loop
diuretics reduce preload and relieve pulmonary congestion
— this is the priority to stabilize oxygenation and
perfusion. BNP elevation supports volume
overload/ventricular strain.
• Why B is incorrect: Patient education is important for long-
term management but not the first action during an acute
exacerbation.
• Why C is incorrect: ECG may be useful to evaluate
ischemia/arrhythmia, but immediate removal of excess
fluid (diuresis) to improve respiratory status is higher
priority.
• Why D is incorrect: Ambulation could worsen pulmonary
edema and is contraindicated during acute fluid overload.
Item 3 — Cardiovascular/Pharmacology (Warfarin
management)
A patient receiving warfarin therapy has an INR of 4.2 and
reports minor epistaxis (small nosebleed). He is
hemodynamically stable and has no major bleeding. Which is
the best initial nursing action?
, A. Continue the current warfarin dose and recheck INR in 1
week.
B. Hold the next warfarin dose and notify the prescriber for
possible oral vitamin K.
C. Administer IV vitamin K now.
D. Call for immediate prothrombin complex concentrate (PCC).
Correct answer: B
Rationale:
• Correct (B): For INR >4.0 with minor bleeding, best
practice commonly includes holding warfarin and
consulting prescriber. Low-dose oral vitamin K may be
advised depending on INR and bleeding. IV vitamin K or
PCC is reserved for serious or life-threatening bleeding.
This approach balances bleeding risk and thrombotic
protection.
• Why A is incorrect: Leaving the dose unchanged with INR
4.2 and active bleeding is unsafe.
• Why C is incorrect: IV vitamin K is used for major bleeding
or very high INR; it carries higher risk (and acts faster) but
is not first choice for minor bleeding.
• Why D is incorrect: PCC is for life-threatening hemorrhage
with urgent reversal needed; not indicated for minor
nosebleed.
