Saunders Comprehensive Review for the NCLEX-PN®
Examination
9th Edition
1) Cardiovascular — Heart Failure (Pathophysiology & Priority
Intervention)
A 68-year-old client with chronic heart failure (reduced ejection
fraction) arrives with increasing dyspnea, bilateral crackles, and
3+ pitting edema. Which nursing action is the highest priority
on admission?
A. Encourage the client to drink more fluids to prevent
dehydration.
B. Place the client in high-Fowler’s position and apply
supplemental oxygen.
C. Administer a prophylactic broad-spectrum antibiotic.
D. Obtain a 12-lead ECG and schedule echocardiogram for
tomorrow.
Answer: B
Rationale — Correct (B): The client shows signs of pulmonary
congestion and fluid overload. High-Fowler’s position reduces
venous return and improves ventilation; supplemental oxygen
addresses hypoxemia and is an immediate priority to maintain
tissue oxygenation. Prompt stabilization of airway/oxygenation
,takes precedence in acute decompensated heart failure.
(AHA/American guidelines emphasize rapid symptom-directed
support in acute heart failure presentations). AHA Journals
Rationale — Incorrect:
• A: Encouraging increased fluids would worsen volume
overload and is contraindicated in acute decompensated
HF.
• C: No evidence of infection; antibiotics are not indicated as
first action.
• D: ECG/echo are important diagnostic studies, but
immediate oxygenation and respiratory support take
priority.
2) Cardiovascular — Lab Interpretation (Anticoagulation)
A client on warfarin therapy for a mechanical mitral valve has
an INR result of 5.6 (therapeutic goal 2.5–3.5). The client is
asymptomatic. Which action should the nurse expect?
A. Administer the scheduled dose of warfarin and recheck INR
in one week.
B. Hold warfarin and notify the provider; prepare to give
vitamin K per orders.
C. Stop all food intake until the INR falls.
D. Increase dietary vitamin K (green leafy vegetables)
immediately.
,Answer: B
Rationale — Correct (B): An INR of 5.6 for a mechanical valve is
above therapeutic range and increases bleeding risk. The
appropriate action is to hold warfarin, notify the provider, and
prepare for vitamin K if ordered or if bleeding risk is significant.
Management depends on degree of elevation and bleeding risk.
Evidence-based anticoagulation protocols guide this approach.
Rationale — Incorrect:
• A: Administering warfarin with such a high INR risks
bleeding.
• C: Withholding oral intake is not an effective intervention
to lower INR.
• D: Dietary changes take days to affect INR and are not
appropriate as immediate corrective action.
3) Respiratory — COPD (Patient Education & Pathophysiology)
A 72-year-old client with long-standing COPD is being
discharged. Which statement by the client indicates correct
understanding of pursed-lip breathing?
A. “Pursed-lip breathing will allow me to breathe faster.”
B. “I should inhale through pursed lips and exhale through my
nose.”
C. “Pursed-lip breathing helps prevent airway collapse during
exhalation.”
, D. “I should use it only when I am sleeping to prevent COPD
worsening.”
Answer: C
Rationale — Correct (C): Pursed-lip breathing increases positive
expiratory pressure, slowing exhalation and preventing small
airway collapse — improving ventilation and reducing dyspnea.
This is a commonly taught self-management technique for
COPD.
Rationale — Incorrect:
• A: Technique aims to slow, not speed, breathing.
• B: Correct technique is inhale slowly through the nose (or
mouth) and exhale through pursed lips; reversed here.
• D: Use during activity or episodes of dyspnea, not only
during sleep.
4) Respiratory — ABG Interpretation
A client with acute asthma exacerbation has an arterial blood
gas: pH 7.49, PaCO₂ 30 mm Hg, HCO₃⁻ 24 mEq/L. The nurse
interprets these results as:
A. Metabolic alkalosis.
B. Respiratory alkalosis.
C. Respiratory acidosis with metabolic compensation.
D. Normal acid-base status.
Examination
9th Edition
1) Cardiovascular — Heart Failure (Pathophysiology & Priority
Intervention)
A 68-year-old client with chronic heart failure (reduced ejection
fraction) arrives with increasing dyspnea, bilateral crackles, and
3+ pitting edema. Which nursing action is the highest priority
on admission?
A. Encourage the client to drink more fluids to prevent
dehydration.
B. Place the client in high-Fowler’s position and apply
supplemental oxygen.
C. Administer a prophylactic broad-spectrum antibiotic.
D. Obtain a 12-lead ECG and schedule echocardiogram for
tomorrow.
Answer: B
Rationale — Correct (B): The client shows signs of pulmonary
congestion and fluid overload. High-Fowler’s position reduces
venous return and improves ventilation; supplemental oxygen
addresses hypoxemia and is an immediate priority to maintain
tissue oxygenation. Prompt stabilization of airway/oxygenation
,takes precedence in acute decompensated heart failure.
(AHA/American guidelines emphasize rapid symptom-directed
support in acute heart failure presentations). AHA Journals
Rationale — Incorrect:
• A: Encouraging increased fluids would worsen volume
overload and is contraindicated in acute decompensated
HF.
• C: No evidence of infection; antibiotics are not indicated as
first action.
• D: ECG/echo are important diagnostic studies, but
immediate oxygenation and respiratory support take
priority.
2) Cardiovascular — Lab Interpretation (Anticoagulation)
A client on warfarin therapy for a mechanical mitral valve has
an INR result of 5.6 (therapeutic goal 2.5–3.5). The client is
asymptomatic. Which action should the nurse expect?
A. Administer the scheduled dose of warfarin and recheck INR
in one week.
B. Hold warfarin and notify the provider; prepare to give
vitamin K per orders.
C. Stop all food intake until the INR falls.
D. Increase dietary vitamin K (green leafy vegetables)
immediately.
,Answer: B
Rationale — Correct (B): An INR of 5.6 for a mechanical valve is
above therapeutic range and increases bleeding risk. The
appropriate action is to hold warfarin, notify the provider, and
prepare for vitamin K if ordered or if bleeding risk is significant.
Management depends on degree of elevation and bleeding risk.
Evidence-based anticoagulation protocols guide this approach.
Rationale — Incorrect:
• A: Administering warfarin with such a high INR risks
bleeding.
• C: Withholding oral intake is not an effective intervention
to lower INR.
• D: Dietary changes take days to affect INR and are not
appropriate as immediate corrective action.
3) Respiratory — COPD (Patient Education & Pathophysiology)
A 72-year-old client with long-standing COPD is being
discharged. Which statement by the client indicates correct
understanding of pursed-lip breathing?
A. “Pursed-lip breathing will allow me to breathe faster.”
B. “I should inhale through pursed lips and exhale through my
nose.”
C. “Pursed-lip breathing helps prevent airway collapse during
exhalation.”
, D. “I should use it only when I am sleeping to prevent COPD
worsening.”
Answer: C
Rationale — Correct (C): Pursed-lip breathing increases positive
expiratory pressure, slowing exhalation and preventing small
airway collapse — improving ventilation and reducing dyspnea.
This is a commonly taught self-management technique for
COPD.
Rationale — Incorrect:
• A: Technique aims to slow, not speed, breathing.
• B: Correct technique is inhale slowly through the nose (or
mouth) and exhale through pursed lips; reversed here.
• D: Use during activity or episodes of dyspnea, not only
during sleep.
4) Respiratory — ABG Interpretation
A client with acute asthma exacerbation has an arterial blood
gas: pH 7.49, PaCO₂ 30 mm Hg, HCO₃⁻ 24 mEq/L. The nurse
interprets these results as:
A. Metabolic alkalosis.
B. Respiratory alkalosis.
C. Respiratory acidosis with metabolic compensation.
D. Normal acid-base status.
