Saunders Comprehensive Review for the NCLEX-PN®
Examination
9th Edition
1 — Cardiovascular — Acute myocardial infarction (AMI)
A 62-year-old man arrives with crushing substernal chest pain
for 90 minutes. ECG shows ST-elevations in leads II, III, aVF. The
nurse prepares the patient for reperfusion therapy. Which
action is the highest nursing priority immediately before
thrombolytic therapy is initiated?
A. Obtain informed consent.
B. Start two large-bore IV lines.
C. Administer aspirin 325 mg chewable.
D. Draw blood for baseline coagulation studies.
Answer: C. Administer aspirin 325 mg chewable.
Rationale:
• Correct (C): Aspirin inhibits platelet aggregation and is
given immediately when AMI is suspected to reduce
mortality; it should be given as early as possible
(chewable). This is the highest priority to reduce clot
propagation while preparing for definitive reperfusion.
, • A (obtain consent): Important for procedures, but
immediate administration of aspirin is a life-saving priority
and typically done as part of initial emergency care.
• B (two large-bore IVs): Important for medication/fluids
access but not higher priority than aspirin in the first
moments.
• D (baseline coag studies): Necessary before thrombolytics
if time permits, but should not delay giving aspirin.
2 — Cardiovascular — Heart failure (HF)
A client with chronic heart failure has weight gain of 4.5 kg (10
lb) over 5 days, bibasilar crackles, and orthopnea. Which
nursing action takes priority?
A. Instruct the client to elevate feet and rest.
B. Administer the prescribed furosemide (loop diuretic) now.
C. Teach low-sodium diet and daily weights.
D. Encourage 2 L of fluid intake daily.
Answer: B. Administer the prescribed furosemide (loop
diuretic) now.
Rationale:
• Correct (B): Rapid weight gain, crackles, and orthopnea
indicate fluid volume overload and possible pulmonary
congestion; immediate diuresis is the priority to relieve
symptoms and prevent respiratory compromise.
, • A (elevate feet & rest): Helpful for edema but does not
address pulmonary congestion.
• C (teach diet/weights): Important for long-term
management but not an immediate intervention for acute
overload.
• D (encourage fluids): Contraindicated in volume overload.
3 — Cardiovascular — Anticoagulation lab interpretation
A patient on warfarin therapy has an INR of 4.6 but no active
bleeding. Which is the nurse’s best action?
A. Administer vitamin K IV immediately.
B. Hold the next warfarin dose and notify provider.
C. Continue warfarin as ordered and recheck INR in 7 days.
D. Give protamine sulfate.
Answer: B. Hold the next warfarin dose and notify provider.
Rationale:
• Correct (B): INR 4.6 is above therapeutic range and
increases bleeding risk; holding warfarin and notifying
provider for further orders (dose adjustment or vitamin K
depending on risk) is appropriate.
• A (vitamin K IV immediately): Reserved for INR >10 or
serious bleeding; IV vitamin K has risks and is not first
action without provider order if bleeding is absent.
, • C (continue and recheck in 7 days): Unsafe—should
address elevated INR sooner.
• D (protamine sulfate): Reverses heparin, not warfarin.
4 — Respiratory — COPD exacerbation (ABG interpretation)
ABG results for a client with COPD exacerbation: pH 7.28, PaCO₂
58 mm Hg, HCO₃⁻ 26 mEq/L. What is the primary acid–base
disturbance?
A. Metabolic acidosis.
B. Acute respiratory acidosis.
C. Chronic respiratory acidosis with compensation.
D. Metabolic alkalosis.
Answer: B. Acute respiratory acidosis.
Rationale:
• Correct (B): Low pH (acidemia) with elevated PaCO₂
indicates respiratory acidosis. HCO₃⁻ is normal (26), so
there is little metabolic compensation yet—consistent with
an acute process.
• A (metabolic acidosis): Would show low HCO₃⁻.
• C (chronic respiratory acidosis with compensation):
Chronic would show elevated HCO₃⁻ reflecting renal
compensation; HCO₃⁻ is not elevated here.
• D (metabolic alkalosis): Not supported.
Examination
9th Edition
1 — Cardiovascular — Acute myocardial infarction (AMI)
A 62-year-old man arrives with crushing substernal chest pain
for 90 minutes. ECG shows ST-elevations in leads II, III, aVF. The
nurse prepares the patient for reperfusion therapy. Which
action is the highest nursing priority immediately before
thrombolytic therapy is initiated?
A. Obtain informed consent.
B. Start two large-bore IV lines.
C. Administer aspirin 325 mg chewable.
D. Draw blood for baseline coagulation studies.
Answer: C. Administer aspirin 325 mg chewable.
Rationale:
• Correct (C): Aspirin inhibits platelet aggregation and is
given immediately when AMI is suspected to reduce
mortality; it should be given as early as possible
(chewable). This is the highest priority to reduce clot
propagation while preparing for definitive reperfusion.
, • A (obtain consent): Important for procedures, but
immediate administration of aspirin is a life-saving priority
and typically done as part of initial emergency care.
• B (two large-bore IVs): Important for medication/fluids
access but not higher priority than aspirin in the first
moments.
• D (baseline coag studies): Necessary before thrombolytics
if time permits, but should not delay giving aspirin.
2 — Cardiovascular — Heart failure (HF)
A client with chronic heart failure has weight gain of 4.5 kg (10
lb) over 5 days, bibasilar crackles, and orthopnea. Which
nursing action takes priority?
A. Instruct the client to elevate feet and rest.
B. Administer the prescribed furosemide (loop diuretic) now.
C. Teach low-sodium diet and daily weights.
D. Encourage 2 L of fluid intake daily.
Answer: B. Administer the prescribed furosemide (loop
diuretic) now.
Rationale:
• Correct (B): Rapid weight gain, crackles, and orthopnea
indicate fluid volume overload and possible pulmonary
congestion; immediate diuresis is the priority to relieve
symptoms and prevent respiratory compromise.
, • A (elevate feet & rest): Helpful for edema but does not
address pulmonary congestion.
• C (teach diet/weights): Important for long-term
management but not an immediate intervention for acute
overload.
• D (encourage fluids): Contraindicated in volume overload.
3 — Cardiovascular — Anticoagulation lab interpretation
A patient on warfarin therapy has an INR of 4.6 but no active
bleeding. Which is the nurse’s best action?
A. Administer vitamin K IV immediately.
B. Hold the next warfarin dose and notify provider.
C. Continue warfarin as ordered and recheck INR in 7 days.
D. Give protamine sulfate.
Answer: B. Hold the next warfarin dose and notify provider.
Rationale:
• Correct (B): INR 4.6 is above therapeutic range and
increases bleeding risk; holding warfarin and notifying
provider for further orders (dose adjustment or vitamin K
depending on risk) is appropriate.
• A (vitamin K IV immediately): Reserved for INR >10 or
serious bleeding; IV vitamin K has risks and is not first
action without provider order if bleeding is absent.
, • C (continue and recheck in 7 days): Unsafe—should
address elevated INR sooner.
• D (protamine sulfate): Reverses heparin, not warfarin.
4 — Respiratory — COPD exacerbation (ABG interpretation)
ABG results for a client with COPD exacerbation: pH 7.28, PaCO₂
58 mm Hg, HCO₃⁻ 26 mEq/L. What is the primary acid–base
disturbance?
A. Metabolic acidosis.
B. Acute respiratory acidosis.
C. Chronic respiratory acidosis with compensation.
D. Metabolic alkalosis.
Answer: B. Acute respiratory acidosis.
Rationale:
• Correct (B): Low pH (acidemia) with elevated PaCO₂
indicates respiratory acidosis. HCO₃⁻ is normal (26), so
there is little metabolic compensation yet—consistent with
an acute process.
• A (metabolic acidosis): Would show low HCO₃⁻.
• C (chronic respiratory acidosis with compensation):
Chronic would show elevated HCO₃⁻ reflecting renal
compensation; HCO₃⁻ is not elevated here.
• D (metabolic alkalosis): Not supported.
