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: Heart failure — priority
intervention)
A 72-year-old woman with known heart failure is
admitted with orthopnea, bibasilar crackles, and
pink frothy sputum. BP 160/92 mm Hg, HR 112,
SpO₂ 88% on room air. What is the nurse’s highest
,priority?
A. Start a low-sodium diet and teach fluid
restrictions.
B. Apply supplemental oxygen and place on
continuous cardiorespiratory monitoring.
C. Administer oral spironolactone per home
medication list.
D. Encourage sitting upright and ambulation to
mobilize secretions.
E. Obtain a basic metabolic panel and BNP level.
Answer: B
Rationale (correct): The client has signs of acute
pulmonary edema and hypoxemia (SpO₂ 88%, pink
frothy sputum). Immediate priority is to support
oxygenation and continuous monitoring to detect
deterioration (ABC principle: airway/breathing first).
Supplemental oxygen and urgent cardiopulmonary
monitoring permit rapid recognition of respiratory
failure and arrhythmias and guide further
interventions (diuretics, vasodilators).
us.elsevierhealth.com
,Why the others are incorrect:
A — Diet education is important but not immediate
in acute respiratory compromise.
C — Spironolactone is not an urgent rescue therapy
for pulmonary edema.
D — Ambulation risks worsening oxygenation and
hemodynamics in acute pulmonary edema.
E — Labs are needed but secondary to stabilizing
oxygenation.
2 — (Cardiovascular: ACS — lab interpretation &
action)
A client arrives with chest pressure. ECG shows 1.5-
mm ST depression in leads II, III, aVF and troponin I
is mildly elevated. Which is the most appropriate
immediate nursing action?
A. Prepare to transfer for emergent percutaneous
coronary intervention (PCI).
B. Administer chewable aspirin (if not
contraindicated) and place on continuous ECG
monitoring.
, C. Reassure the client that normal CK-MB rules out
myocardial infarction.
D. Give sublingual nitroglycerin and discharge if pain
resolves.
E. Obtain a pulmonary embolism panel.
Answer: B
Rationale (correct): ST depression with elevated
troponin suggests an acute coronary syndrome
(non-ST elevation myocardial infarction — NSTEMI).
Immediate actions per chest pain protocols are to
administer antiplatelet therapy (aspirin) unless
contraindicated, provide continuous cardiac
monitoring, supplemental oxygen if hypoxic, and
notify the provider for further management. Urgent
PCI is indicated for STEMI or refractory ischemia;
NSTEMI care is guided by risk stratification.
us.elsevierhealth.com
Why incorrect:
A — Emergent PCI is typically for STEMI with
persistent ST elevation — not indicated solely for ST
depression.
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: Heart failure — priority
intervention)
A 72-year-old woman with known heart failure is
admitted with orthopnea, bibasilar crackles, and
pink frothy sputum. BP 160/92 mm Hg, HR 112,
SpO₂ 88% on room air. What is the nurse’s highest
,priority?
A. Start a low-sodium diet and teach fluid
restrictions.
B. Apply supplemental oxygen and place on
continuous cardiorespiratory monitoring.
C. Administer oral spironolactone per home
medication list.
D. Encourage sitting upright and ambulation to
mobilize secretions.
E. Obtain a basic metabolic panel and BNP level.
Answer: B
Rationale (correct): The client has signs of acute
pulmonary edema and hypoxemia (SpO₂ 88%, pink
frothy sputum). Immediate priority is to support
oxygenation and continuous monitoring to detect
deterioration (ABC principle: airway/breathing first).
Supplemental oxygen and urgent cardiopulmonary
monitoring permit rapid recognition of respiratory
failure and arrhythmias and guide further
interventions (diuretics, vasodilators).
us.elsevierhealth.com
,Why the others are incorrect:
A — Diet education is important but not immediate
in acute respiratory compromise.
C — Spironolactone is not an urgent rescue therapy
for pulmonary edema.
D — Ambulation risks worsening oxygenation and
hemodynamics in acute pulmonary edema.
E — Labs are needed but secondary to stabilizing
oxygenation.
2 — (Cardiovascular: ACS — lab interpretation &
action)
A client arrives with chest pressure. ECG shows 1.5-
mm ST depression in leads II, III, aVF and troponin I
is mildly elevated. Which is the most appropriate
immediate nursing action?
A. Prepare to transfer for emergent percutaneous
coronary intervention (PCI).
B. Administer chewable aspirin (if not
contraindicated) and place on continuous ECG
monitoring.
, C. Reassure the client that normal CK-MB rules out
myocardial infarction.
D. Give sublingual nitroglycerin and discharge if pain
resolves.
E. Obtain a pulmonary embolism panel.
Answer: B
Rationale (correct): ST depression with elevated
troponin suggests an acute coronary syndrome
(non-ST elevation myocardial infarction — NSTEMI).
Immediate actions per chest pain protocols are to
administer antiplatelet therapy (aspirin) unless
contraindicated, provide continuous cardiac
monitoring, supplemental oxygen if hypoxic, and
notify the provider for further management. Urgent
PCI is indicated for STEMI or refractory ischemia;
NSTEMI care is guided by risk stratification.
us.elsevierhealth.com
Why incorrect:
A — Emergent PCI is typically for STEMI with
persistent ST elevation — not indicated solely for ST
depression.
