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)
Q1 — Cardiovascular (Myocardial infarction:
priority nursing action)
A 62-year-old man arrives to the emergency
department with chest pain rated 8/10, diaphoresis,
and shortness of breath. ECG shows ST-segment
elevation in leads V2–V5. Which is the nurse’s
highest priority action?
,A. Give sublingual nitroglycerin.
B. Start oxygen via nasal cannula at 2 L/min.
C. Prepare the client for immediate reperfusion
therapy (PCI) and notify cardiology.
D. Obtain a stat chest X-ray.
Answer: C
Rationale (Correct): ST-elevation MI requires timely
reperfusion (ideally PCI within guideline door-to-
balloon times). Preparing for immediate reperfusion
and activating the cath lab/cardiology is the priority
to limit myocardial damage. (Reperfusion is time-
sensitive — highest priority.)
Rationale (Incorrect):
A. Nitroglycerin reduces chest pain and can help
ischemia but must follow initial assessment and is
not higher priority than reperfusion activation.
B. Give oxygen only if hypoxemic (SpO₂ < 90%) or in
distress; routine O₂ for all MI is not always first
priority.
D. Chest X-ray is not needed before reperfusion and
will delay definitive therapy.
,Q2 — Cardiovascular (Heart failure: med and
patient education)
A client with chronic heart failure is prescribed
spironolactone 25 mg daily. What patient teaching is
most important?
A. “Take this medication with a high-potassium diet
to prevent cramps.”
B. “Avoid potassium supplements and salt
substitutes that contain potassium.”
C. “Expect a rapid increase in urine output within 1
hour.”
D. “If you develop a dry cough, stop the medication
immediately.”
Answer: B
Rationale (Correct): Spironolactone is a potassium-
sparing diuretic; risk of hyperkalemia means the
client must avoid potassium supplements and
potassium-containing salt substitutes. Patient
education to monitor K and avoid excess K is
essential.
, Rationale (Incorrect):
A. High-potassium diet increases hyperkalemia risk
— not advised.
C. Spironolactone’s diuresis is modest and not
abrupt; rapid large urine output is not expected.
D. Dry cough is associated with ACE inhibitors, not
spironolactone.
Q3 — Cardiovascular (Anticoagulation: lab
monitoring)
A client on continuous intravenous unfractionated
heparin for a pulmonary embolus has an activated
partial thromboplastin time (aPTT) of 110 seconds
(therapeutic range per protocol 60–100 s). The
priority nursing action is:
A. Increase the heparin infusion rate.
B. Decrease the heparin infusion rate.
C. Stop the heparin infusion and call the provider.
D. Document the value and continue current rate.
Answer: B
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)
Q1 — Cardiovascular (Myocardial infarction:
priority nursing action)
A 62-year-old man arrives to the emergency
department with chest pain rated 8/10, diaphoresis,
and shortness of breath. ECG shows ST-segment
elevation in leads V2–V5. Which is the nurse’s
highest priority action?
,A. Give sublingual nitroglycerin.
B. Start oxygen via nasal cannula at 2 L/min.
C. Prepare the client for immediate reperfusion
therapy (PCI) and notify cardiology.
D. Obtain a stat chest X-ray.
Answer: C
Rationale (Correct): ST-elevation MI requires timely
reperfusion (ideally PCI within guideline door-to-
balloon times). Preparing for immediate reperfusion
and activating the cath lab/cardiology is the priority
to limit myocardial damage. (Reperfusion is time-
sensitive — highest priority.)
Rationale (Incorrect):
A. Nitroglycerin reduces chest pain and can help
ischemia but must follow initial assessment and is
not higher priority than reperfusion activation.
B. Give oxygen only if hypoxemic (SpO₂ < 90%) or in
distress; routine O₂ for all MI is not always first
priority.
D. Chest X-ray is not needed before reperfusion and
will delay definitive therapy.
,Q2 — Cardiovascular (Heart failure: med and
patient education)
A client with chronic heart failure is prescribed
spironolactone 25 mg daily. What patient teaching is
most important?
A. “Take this medication with a high-potassium diet
to prevent cramps.”
B. “Avoid potassium supplements and salt
substitutes that contain potassium.”
C. “Expect a rapid increase in urine output within 1
hour.”
D. “If you develop a dry cough, stop the medication
immediately.”
Answer: B
Rationale (Correct): Spironolactone is a potassium-
sparing diuretic; risk of hyperkalemia means the
client must avoid potassium supplements and
potassium-containing salt substitutes. Patient
education to monitor K and avoid excess K is
essential.
, Rationale (Incorrect):
A. High-potassium diet increases hyperkalemia risk
— not advised.
C. Spironolactone’s diuresis is modest and not
abrupt; rapid large urine output is not expected.
D. Dry cough is associated with ACE inhibitors, not
spironolactone.
Q3 — Cardiovascular (Anticoagulation: lab
monitoring)
A client on continuous intravenous unfractionated
heparin for a pulmonary embolus has an activated
partial thromboplastin time (aPTT) of 110 seconds
(therapeutic range per protocol 60–100 s). The
priority nursing action is:
A. Increase the heparin infusion rate.
B. Decrease the heparin infusion rate.
C. Stop the heparin infusion and call the provider.
D. Document the value and continue current rate.
Answer: B
