Saunders Comprehensive Review for the NCLEX-PN®
Examination
9th Edition
Author(s)Linda Anne Silvestri; Angela Silvestri
TEST BANK
Test-bank style items — Medical-Surgical Nursing
(Cardiovascular, Respiratory, Neurological, GI,
Renal, Endocrine, Musculoskeletal)
1) (Cardiovascular — Pathophysiology / Priority
intervention)
A 68-year-old man is admitted with progressive
exertional dyspnea, bibasilar crackles, and 2+
bilateral pitting edema. BNP is elevated. Which
nursing action is the highest priority on admission?
A. Instruct the client about a low-sodium diet.
,B. Place the client on continuous pulse oximetry and
apply supplemental oxygen as needed.
C. Obtain a 12-lead ECG and notify the provider of
dysrhythmias.
D. Measure daily weights and document strict intake
and output.
E. Begin teaching about home medication regimen
(ACE inhibitor, diuretic).
Answer: B
Rationale (correct): The client presents with signs of
acute decompensated heart failure (dyspnea,
crackles, edema, elevated BNP). Ensuring adequate
oxygenation is the immediate priority because
compromised gas exchange and hypoxia can cause
deterioration. Placing on continuous pulse oximetry
and applying supplemental oxygen (if hypoxemic)
addresses airway/breathing — the first step in ABC
prioritization. Evidence-based heart failure care
emphasizes rapid assessment of oxygenation and
respiratory status. Evolve+1
,Rationale (incorrect answers):
A — Low-sodium diet education is important but
not the immediate priority in acute
decompensation.
C — ECG is appropriate (arrhythmias can precipitate
decompensation) but oxygenation takes
precedence.
D — Daily weights and I&O are essential for ongoing
management but are secondary to stabilizing
oxygenation.
E — Medication teaching is important for discharge
planning but not immediate.
2) (Cardiovascular — Lab interpretation / Nursing
action)
A client with chest pain has the following labs:
troponin I slightly elevated, CK-MB normal, ECG
with ST-segment depression in leads V4–V6. Which
interpretation and nursing action is most
appropriate?
A. The client is having an acute ST-elevation
, myocardial infarction (STEMI); prepare for emergent
PCI.
B. Findings suggest non-ST-elevation myocardial
ischemia (NSTEMI/unstable angina); administer
prescribed antiplatelet and notify provider.
C. Troponin elevation is nonspecific; continue
routine monitoring only.
D. Normal CK-MB rules out myocardial injury; treat
pain with opioids and discharge if pain resolves.
E. ST depressions indicate pericarditis; prepare for
anti-inflammatory therapy.
Answer: B
Rationale (correct): A modest troponin rise with ST-
segment depression suggests myocardial ischemia
or a non-ST-elevation acute coronary syndrome
(NSTEMI). Nursing priorities include administering
prescribed antiplatelet agents (e.g., aspirin) and
anti-ischemic medications per protocol, continuous
cardiac monitoring, and notifying the
provider/activating chest pain pathway. STEMI is
characterized by ST-segment elevation in leads
Examination
9th Edition
Author(s)Linda Anne Silvestri; Angela Silvestri
TEST BANK
Test-bank style items — Medical-Surgical Nursing
(Cardiovascular, Respiratory, Neurological, GI,
Renal, Endocrine, Musculoskeletal)
1) (Cardiovascular — Pathophysiology / Priority
intervention)
A 68-year-old man is admitted with progressive
exertional dyspnea, bibasilar crackles, and 2+
bilateral pitting edema. BNP is elevated. Which
nursing action is the highest priority on admission?
A. Instruct the client about a low-sodium diet.
,B. Place the client on continuous pulse oximetry and
apply supplemental oxygen as needed.
C. Obtain a 12-lead ECG and notify the provider of
dysrhythmias.
D. Measure daily weights and document strict intake
and output.
E. Begin teaching about home medication regimen
(ACE inhibitor, diuretic).
Answer: B
Rationale (correct): The client presents with signs of
acute decompensated heart failure (dyspnea,
crackles, edema, elevated BNP). Ensuring adequate
oxygenation is the immediate priority because
compromised gas exchange and hypoxia can cause
deterioration. Placing on continuous pulse oximetry
and applying supplemental oxygen (if hypoxemic)
addresses airway/breathing — the first step in ABC
prioritization. Evidence-based heart failure care
emphasizes rapid assessment of oxygenation and
respiratory status. Evolve+1
,Rationale (incorrect answers):
A — Low-sodium diet education is important but
not the immediate priority in acute
decompensation.
C — ECG is appropriate (arrhythmias can precipitate
decompensation) but oxygenation takes
precedence.
D — Daily weights and I&O are essential for ongoing
management but are secondary to stabilizing
oxygenation.
E — Medication teaching is important for discharge
planning but not immediate.
2) (Cardiovascular — Lab interpretation / Nursing
action)
A client with chest pain has the following labs:
troponin I slightly elevated, CK-MB normal, ECG
with ST-segment depression in leads V4–V6. Which
interpretation and nursing action is most
appropriate?
A. The client is having an acute ST-elevation
, myocardial infarction (STEMI); prepare for emergent
PCI.
B. Findings suggest non-ST-elevation myocardial
ischemia (NSTEMI/unstable angina); administer
prescribed antiplatelet and notify provider.
C. Troponin elevation is nonspecific; continue
routine monitoring only.
D. Normal CK-MB rules out myocardial injury; treat
pain with opioids and discharge if pain resolves.
E. ST depressions indicate pericarditis; prepare for
anti-inflammatory therapy.
Answer: B
Rationale (correct): A modest troponin rise with ST-
segment depression suggests myocardial ischemia
or a non-ST-elevation acute coronary syndrome
(NSTEMI). Nursing priorities include administering
prescribed antiplatelet agents (e.g., aspirin) and
anti-ischemic medications per protocol, continuous
cardiac monitoring, and notifying the
provider/activating chest pain pathway. STEMI is
characterized by ST-segment elevation in leads
