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 — BNP & priority
action)
A 72-year-old client with chronic heart failure
reports increasing dyspnea on exertion and
orthopnea. The nurse notes edema in both lower
extremities and orders a BNP, which returns 1200
,pg/mL (markedly elevated). Which action should
the nurse take first?
A. Administer the scheduled lisinopril (ACE
inhibitor).
B. Elevate the head of the bed and administer
supplemental oxygen as ordered.
C. Offer a low-sodium diet and explain fluid
restrictions.
D. Weigh the client and compare with prior weights.
Answer: B
Rationale — Correct (B): Elevated BNP suggests
volume overload/heart failure exacerbation. The
immediate priority is to optimize oxygenation (ABC
principle): elevate HOB to improve ventilation and
give supplemental oxygen as ordered to relieve
hypoxemia and reduce work of breathing. This
stabilizes the client before other interventions.
Rationale — Incorrect:
A. Lisinopril is important long-term to reduce
afterload and remodeling but is not the immediate
priority for acute dyspnea and hypoxia.
,C. Education on sodium and fluid is essential but is a
non-urgent, secondary intervention.
D. Daily weights are valuable for trend monitoring
but do not immediately improve oxygenation or
relieve acute symptoms.
2 — Cardiovascular (Acute MI — priority nursing
action)
A client is admitted with chest pain and ST-
elevations on ECG consistent with an acute anterior
MI. The nurse’s most immediate priority is to:
A. Administer sublingual nitroglycerin unless
contraindicated.
B. Obtain a complete lipid panel.
C. Begin teaching about lifestyle modification after
discharge.
D. Schedule an echocardiogram for tomorrow.
Answer: A
Rationale — Correct (A): For suspected acute MI,
rapid reperfusion and symptom relief are critical:
, sublingual nitroglycerin (unless hypotensive or on
phosphodiesterase inhibitors) reduces ischemic pain
by vasodilation. This matches the ABC and time-
sensitive interventions for myocardial ischemia.
Rationale — Incorrect:
B. Lipid panel is useful long-term but not emergent.
C. Discharge teaching is important but deferred until
patient is stable.
D. Echocardiogram is useful for function assessment
but is not the immediate priority over pain relief
and reperfusion measures.
3 — Cardiovascular (Anticoagulation — lab
interpretation)
A client on warfarin for atrial fibrillation has an INR
result of 1.2 (therapeutic target 2.0–3.0). Which
nursing action is appropriate?
A. Hold the warfarin and call to request vitamin K.
B. Administer the scheduled warfarin dose and
notify the provider.
C. Administer a loading dose of heparin
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 — BNP & priority
action)
A 72-year-old client with chronic heart failure
reports increasing dyspnea on exertion and
orthopnea. The nurse notes edema in both lower
extremities and orders a BNP, which returns 1200
,pg/mL (markedly elevated). Which action should
the nurse take first?
A. Administer the scheduled lisinopril (ACE
inhibitor).
B. Elevate the head of the bed and administer
supplemental oxygen as ordered.
C. Offer a low-sodium diet and explain fluid
restrictions.
D. Weigh the client and compare with prior weights.
Answer: B
Rationale — Correct (B): Elevated BNP suggests
volume overload/heart failure exacerbation. The
immediate priority is to optimize oxygenation (ABC
principle): elevate HOB to improve ventilation and
give supplemental oxygen as ordered to relieve
hypoxemia and reduce work of breathing. This
stabilizes the client before other interventions.
Rationale — Incorrect:
A. Lisinopril is important long-term to reduce
afterload and remodeling but is not the immediate
priority for acute dyspnea and hypoxia.
,C. Education on sodium and fluid is essential but is a
non-urgent, secondary intervention.
D. Daily weights are valuable for trend monitoring
but do not immediately improve oxygenation or
relieve acute symptoms.
2 — Cardiovascular (Acute MI — priority nursing
action)
A client is admitted with chest pain and ST-
elevations on ECG consistent with an acute anterior
MI. The nurse’s most immediate priority is to:
A. Administer sublingual nitroglycerin unless
contraindicated.
B. Obtain a complete lipid panel.
C. Begin teaching about lifestyle modification after
discharge.
D. Schedule an echocardiogram for tomorrow.
Answer: A
Rationale — Correct (A): For suspected acute MI,
rapid reperfusion and symptom relief are critical:
, sublingual nitroglycerin (unless hypotensive or on
phosphodiesterase inhibitors) reduces ischemic pain
by vasodilation. This matches the ABC and time-
sensitive interventions for myocardial ischemia.
Rationale — Incorrect:
B. Lipid panel is useful long-term but not emergent.
C. Discharge teaching is important but deferred until
patient is stable.
D. Echocardiogram is useful for function assessment
but is not the immediate priority over pain relief
and reperfusion measures.
3 — Cardiovascular (Anticoagulation — lab
interpretation)
A client on warfarin for atrial fibrillation has an INR
result of 1.2 (therapeutic target 2.0–3.0). Which
nursing action is appropriate?
A. Hold the warfarin and call to request vitamin K.
B. Administer the scheduled warfarin dose and
notify the provider.
C. Administer a loading dose of heparin
