TEST BANK FOR BRUNNER &
SUDDARTH’S TEXTBOOK OF
MEDICAL-SURGICAL NURSING
15TH EDITION
UPDATED 2026/2027
COMPREHENSIVE ADULT HEALTH
NURSING EXAM RESOURCE
Advanced Medical-Surgical Concepts,
Clinical Judgment, and Next Generation
NCLEX (NGN) Application
Prepared for: Advanced Nursing Practice and Education Subject: Medical-Surgical Nursing
Edition Alignment: 15th Edition (Hinkle & Cheever) Guideline Integration: 2024-2027 Clinical
Practice Updates
Unit I: Cardiovascular and Circulatory Function
Question 1: Advanced Heart Failure Management and
Guideline-Directed Medical Therapy (GDMT)
Clinical Scenario: A 68-year-old male with a history of hypertension and a previous myocardial
infarction (MI) presents to the heart failure clinic for a follow-up. He reports increasing fatigue
and dyspnea on exertion, classifying him as NYHA Class III. His most recent echocardiogram
reveals a left ventricular ejection fraction (LVEF) of 32%. He is currently compliant with
Carvedilol 25 mg BID and Lisinopril 20 mg daily. His vital signs are BP 130/80 mmHg, HR 72
bpm, and serum potassium is 4.2 mEq/L. According to the 2022 AHA/ACC/HFSA Guidelines for
the Management of Heart Failure and subsequent 2026 updates, which pharmacological
adjustment provides the highest economic and clinical value for this patient to reduce mortality
and hospitalization?
A. Increase the Lisinopril dosage to 40 mg daily to maximize ACE inhibitor blockade. B. Add
,Digoxin 0.125 mg daily for inotropic support and symptom management. C. Switch Lisinopril to
Sacubitril/Valsartan (ARNI) and initiate Dapagliflozin (SGLT2 inhibitor). D. Initiate Amlodipine 5
mg daily to better control afterload and blood pressure.
Correct Answer: C. Switch Lisinopril to Sacubitril/Valsartan (ARNI) and initiate Dapagliflozin
(SGLT2 inhibitor).
Comprehensive Rationale and Clinical Analysis: The management of Heart Failure with
Reduced Ejection Fraction (HFrEF) has undergone a paradigm shift from a sequential treatment
approach to a simultaneous "four-pillar" strategy of Guideline-Directed Medical Therapy
(GDMT). The 2022 AHA/ACC/HFSA Guidelines, validated by ongoing research into 2026,
strongly recommend the replacement of Angiotensin-Converting Enzyme (ACE) inhibitors with
Angiotensin Receptor-Neprilysin Inhibitors (ARNIs), such as Sacubitril/Valsartan, for patients
with symptomatic HFrEF who tolerate ACE inhibitors. This switch is classified as a Class I
recommendation with "High Value" due to the demonstrated superiority of ARNIs in reducing
cardiovascular death and heart failure hospitalizations compared to ACE inhibitors alone. The
mechanism involves the simultaneous inhibition of neprilysin (which degrades beneficial
natriuretic peptides) and the angiotensin II receptor, promoting vasodilation and natriuresis while
blocking the maladaptive renin-angiotensin-aldosterone system (RAAS).
Concurrently, the addition of a Sodium-Glucose Cotransporter-2 (SGLT2) inhibitor, such as
Dapagliflozin or Empagliflozin, is now a standard of care (Class I recommendation) for HFrEF
regardless of diabetes status. SGLT2 inhibitors have shown consistent reductions in heart
failure hospitalization and cardiovascular mortality. Their mechanism in heart failure is
multifaceted, involving osmotic diuresis, reduction in preload and afterload, improvement in
myocardial energetics, and reduction in interstitial fibrosis.
Distractor Analysis: Option A is incorrect because while maximizing ACE inhibitor dosing is
beneficial, the evidence unequivocally supports switching to an ARNI for superior mortality
outcomes in HFrEF. Continuing an ACE inhibitor when an ARNI is feasible deprives the patient
of the added survival benefit of neprilysin inhibition. Option B is incorrect because Digoxin is
largely considered a second- or third-line agent. While it may reduce hospitalizations in patients
with severe symptoms despite optimal GDMT, it has no proven mortality benefit and a narrow
therapeutic index. It is not part of the core "four pillars" (ARNI, Beta-blocker, MRA, SGLT2i).
Option D is incorrect because calcium channel blockers like Amlodipine do not improve survival
in heart failure. They are neutral regarding mortality and are typically reserved for blood
pressure control only after all other GDMT options have been exhausted.
Nursing Implications: Nurses must monitor for hypotension, renal function changes, and
angioedema when transitioning patients to ARNI therapy. A mandatory 36-hour washout period
is required when switching from an ACE inhibitor to an ARNI to prevent angioedema.
Question 2: Hemodynamic Monitoring and Waveform Interpretation
Clinical Scenario: A patient in the Cardiac Intensive Care Unit (CICU) with cardiogenic shock
has a Pulmonary Artery Catheter (PAC) in place. The nurse observes the bedside monitor and
notes a waveform characterized by a rapid systolic upstroke, a dicrotic notch, and a diastolic
pressure of 12 mmHg. The physician asks for the Pulmonary Artery Wedge Pressure (PAWP).
The nurse inflates the balloon with 1.5 mL of air. Which physiological event does the resulting
PAWP waveform represent, and what is the expected pressure range for a healthy adult?
A. Right ventricular systolic contraction; 15–25 mmHg. B. Left atrial filling pressure/Left
ventricular end-diastolic pressure; 6–12 mmHg. C. Systemic vascular resistance; 800–1200
dynes/sec/cm⁻⁵. D. Right atrial pressure and venous return; 2–6 mmHg.
, Correct Answer: B. Left atrial filling pressure/Left ventricular end-diastolic pressure; 6–12
mmHg.
Comprehensive Rationale and Clinical Analysis: Hemodynamic monitoring via a Pulmonary
Artery Catheter (PAC) is crucial for differentiating shock states (cardiogenic vs. distributive vs.
hypovolemic) and managing fluid status in critically ill patients. The Pulmonary Artery Wedge
Pressure (PAWP), also known as Pulmonary Artery Occlusion Pressure (PAOP), is obtained
when the balloon at the tip of the catheter is inflated, momentarily occluding forward flow in a
branch of the pulmonary artery. During this occlusion, the static column of blood distally creates
a conductive pathway to the left atrium. Since there are no valves between the pulmonary
capillaries and the left atrium (during diastole when the mitral valve is open), the pressure
measured at the distal tip of the catheter equilibrates with the Left Atrial Pressure (LAP) and,
by extension, the Left Ventricular End-Diastolic Pressure (LVEDP). This provides an indirect
measure of left ventricular preload.
The PAWP waveform typically exhibits two positive deflections (a and v waves) and two
negative deflections (x and y descents). The 'a' wave corresponds to left atrial contraction, and
the 'v' wave corresponds to passive left atrial filling during ventricular systole against a closed
mitral valve. The normal range for PAWP is approximately 6–12 mmHg. In cardiogenic shock,
this value is typically elevated (>18 mmHg), indicating left ventricular failure and pulmonary
congestion.
Distractor Analysis: Option A refers to the Right Ventricular (RV) waveform, which is pulsatile
with a systolic pressure of 15–25 mmHg but a diastolic pressure near zero (0–5 mmHg). The RV
waveform is observed during catheter insertion but is not the "wedged" waveform. Option C
describes Systemic Vascular Resistance (SVR), which is a calculated hemodynamic parameter
derived from MAP, CVP, and Cardiac Output. It represents the afterload the left ventricle must
overcome and is not a direct pressure measurement. Option D refers to Right Atrial Pressure
(RAP) or Central Venous Pressure (CVP), measured by the proximal port of the PAC sitting in
the right atrium. While valuable for right-sided preload, it does not reflect left-sided heart
function directly.
Nursing Implications: Nurses must ensure the balloon is not left inflated for prolonged periods
(seconds only) to prevent pulmonary artery rupture or infarction. The monitor tracing must be
observed continuously during inflation, and the syringe should be allowed to passively deflate
immediately after the mean pressure is recorded.
Question 3: Acute Myocardial Infarction and Gender-Specific
Presentations
Clinical Scenario: A 52-year-old female presents to the Emergency Department complaining of
profound fatigue, shortness of breath, and epigastric burning sensation that has persisted for 4
hours. She denies "crushing" chest pain but states her "bra feels too tight." She has a history of
type 2 diabetes. A 12-lead ECG reveals ST-segment elevation in leads II, III, and aVF. Which
nursing action is the priority, and what is the likely diagnosis?
A. Administer aluminum hydroxide/magnesium hydroxide for suspected GERD; Inferior Wall MI.
B. Initiate the hospital's ACS protocol including oxygen, aspirin, and preparation for PCI; Inferior
Wall MI. C. Prepare for an abdominal ultrasound to rule out cholecystitis; Anterior Wall MI. D.
Administer sublingual nitroglycerin and monitor for headache; Lateral Wall MI.
Correct Answer: B. Initiate the hospital's ACS protocol including oxygen, aspirin, and
preparation for PCI; Inferior Wall MI.
SUDDARTH’S TEXTBOOK OF
MEDICAL-SURGICAL NURSING
15TH EDITION
UPDATED 2026/2027
COMPREHENSIVE ADULT HEALTH
NURSING EXAM RESOURCE
Advanced Medical-Surgical Concepts,
Clinical Judgment, and Next Generation
NCLEX (NGN) Application
Prepared for: Advanced Nursing Practice and Education Subject: Medical-Surgical Nursing
Edition Alignment: 15th Edition (Hinkle & Cheever) Guideline Integration: 2024-2027 Clinical
Practice Updates
Unit I: Cardiovascular and Circulatory Function
Question 1: Advanced Heart Failure Management and
Guideline-Directed Medical Therapy (GDMT)
Clinical Scenario: A 68-year-old male with a history of hypertension and a previous myocardial
infarction (MI) presents to the heart failure clinic for a follow-up. He reports increasing fatigue
and dyspnea on exertion, classifying him as NYHA Class III. His most recent echocardiogram
reveals a left ventricular ejection fraction (LVEF) of 32%. He is currently compliant with
Carvedilol 25 mg BID and Lisinopril 20 mg daily. His vital signs are BP 130/80 mmHg, HR 72
bpm, and serum potassium is 4.2 mEq/L. According to the 2022 AHA/ACC/HFSA Guidelines for
the Management of Heart Failure and subsequent 2026 updates, which pharmacological
adjustment provides the highest economic and clinical value for this patient to reduce mortality
and hospitalization?
A. Increase the Lisinopril dosage to 40 mg daily to maximize ACE inhibitor blockade. B. Add
,Digoxin 0.125 mg daily for inotropic support and symptom management. C. Switch Lisinopril to
Sacubitril/Valsartan (ARNI) and initiate Dapagliflozin (SGLT2 inhibitor). D. Initiate Amlodipine 5
mg daily to better control afterload and blood pressure.
Correct Answer: C. Switch Lisinopril to Sacubitril/Valsartan (ARNI) and initiate Dapagliflozin
(SGLT2 inhibitor).
Comprehensive Rationale and Clinical Analysis: The management of Heart Failure with
Reduced Ejection Fraction (HFrEF) has undergone a paradigm shift from a sequential treatment
approach to a simultaneous "four-pillar" strategy of Guideline-Directed Medical Therapy
(GDMT). The 2022 AHA/ACC/HFSA Guidelines, validated by ongoing research into 2026,
strongly recommend the replacement of Angiotensin-Converting Enzyme (ACE) inhibitors with
Angiotensin Receptor-Neprilysin Inhibitors (ARNIs), such as Sacubitril/Valsartan, for patients
with symptomatic HFrEF who tolerate ACE inhibitors. This switch is classified as a Class I
recommendation with "High Value" due to the demonstrated superiority of ARNIs in reducing
cardiovascular death and heart failure hospitalizations compared to ACE inhibitors alone. The
mechanism involves the simultaneous inhibition of neprilysin (which degrades beneficial
natriuretic peptides) and the angiotensin II receptor, promoting vasodilation and natriuresis while
blocking the maladaptive renin-angiotensin-aldosterone system (RAAS).
Concurrently, the addition of a Sodium-Glucose Cotransporter-2 (SGLT2) inhibitor, such as
Dapagliflozin or Empagliflozin, is now a standard of care (Class I recommendation) for HFrEF
regardless of diabetes status. SGLT2 inhibitors have shown consistent reductions in heart
failure hospitalization and cardiovascular mortality. Their mechanism in heart failure is
multifaceted, involving osmotic diuresis, reduction in preload and afterload, improvement in
myocardial energetics, and reduction in interstitial fibrosis.
Distractor Analysis: Option A is incorrect because while maximizing ACE inhibitor dosing is
beneficial, the evidence unequivocally supports switching to an ARNI for superior mortality
outcomes in HFrEF. Continuing an ACE inhibitor when an ARNI is feasible deprives the patient
of the added survival benefit of neprilysin inhibition. Option B is incorrect because Digoxin is
largely considered a second- or third-line agent. While it may reduce hospitalizations in patients
with severe symptoms despite optimal GDMT, it has no proven mortality benefit and a narrow
therapeutic index. It is not part of the core "four pillars" (ARNI, Beta-blocker, MRA, SGLT2i).
Option D is incorrect because calcium channel blockers like Amlodipine do not improve survival
in heart failure. They are neutral regarding mortality and are typically reserved for blood
pressure control only after all other GDMT options have been exhausted.
Nursing Implications: Nurses must monitor for hypotension, renal function changes, and
angioedema when transitioning patients to ARNI therapy. A mandatory 36-hour washout period
is required when switching from an ACE inhibitor to an ARNI to prevent angioedema.
Question 2: Hemodynamic Monitoring and Waveform Interpretation
Clinical Scenario: A patient in the Cardiac Intensive Care Unit (CICU) with cardiogenic shock
has a Pulmonary Artery Catheter (PAC) in place. The nurse observes the bedside monitor and
notes a waveform characterized by a rapid systolic upstroke, a dicrotic notch, and a diastolic
pressure of 12 mmHg. The physician asks for the Pulmonary Artery Wedge Pressure (PAWP).
The nurse inflates the balloon with 1.5 mL of air. Which physiological event does the resulting
PAWP waveform represent, and what is the expected pressure range for a healthy adult?
A. Right ventricular systolic contraction; 15–25 mmHg. B. Left atrial filling pressure/Left
ventricular end-diastolic pressure; 6–12 mmHg. C. Systemic vascular resistance; 800–1200
dynes/sec/cm⁻⁵. D. Right atrial pressure and venous return; 2–6 mmHg.
, Correct Answer: B. Left atrial filling pressure/Left ventricular end-diastolic pressure; 6–12
mmHg.
Comprehensive Rationale and Clinical Analysis: Hemodynamic monitoring via a Pulmonary
Artery Catheter (PAC) is crucial for differentiating shock states (cardiogenic vs. distributive vs.
hypovolemic) and managing fluid status in critically ill patients. The Pulmonary Artery Wedge
Pressure (PAWP), also known as Pulmonary Artery Occlusion Pressure (PAOP), is obtained
when the balloon at the tip of the catheter is inflated, momentarily occluding forward flow in a
branch of the pulmonary artery. During this occlusion, the static column of blood distally creates
a conductive pathway to the left atrium. Since there are no valves between the pulmonary
capillaries and the left atrium (during diastole when the mitral valve is open), the pressure
measured at the distal tip of the catheter equilibrates with the Left Atrial Pressure (LAP) and,
by extension, the Left Ventricular End-Diastolic Pressure (LVEDP). This provides an indirect
measure of left ventricular preload.
The PAWP waveform typically exhibits two positive deflections (a and v waves) and two
negative deflections (x and y descents). The 'a' wave corresponds to left atrial contraction, and
the 'v' wave corresponds to passive left atrial filling during ventricular systole against a closed
mitral valve. The normal range for PAWP is approximately 6–12 mmHg. In cardiogenic shock,
this value is typically elevated (>18 mmHg), indicating left ventricular failure and pulmonary
congestion.
Distractor Analysis: Option A refers to the Right Ventricular (RV) waveform, which is pulsatile
with a systolic pressure of 15–25 mmHg but a diastolic pressure near zero (0–5 mmHg). The RV
waveform is observed during catheter insertion but is not the "wedged" waveform. Option C
describes Systemic Vascular Resistance (SVR), which is a calculated hemodynamic parameter
derived from MAP, CVP, and Cardiac Output. It represents the afterload the left ventricle must
overcome and is not a direct pressure measurement. Option D refers to Right Atrial Pressure
(RAP) or Central Venous Pressure (CVP), measured by the proximal port of the PAC sitting in
the right atrium. While valuable for right-sided preload, it does not reflect left-sided heart
function directly.
Nursing Implications: Nurses must ensure the balloon is not left inflated for prolonged periods
(seconds only) to prevent pulmonary artery rupture or infarction. The monitor tracing must be
observed continuously during inflation, and the syringe should be allowed to passively deflate
immediately after the mean pressure is recorded.
Question 3: Acute Myocardial Infarction and Gender-Specific
Presentations
Clinical Scenario: A 52-year-old female presents to the Emergency Department complaining of
profound fatigue, shortness of breath, and epigastric burning sensation that has persisted for 4
hours. She denies "crushing" chest pain but states her "bra feels too tight." She has a history of
type 2 diabetes. A 12-lead ECG reveals ST-segment elevation in leads II, III, and aVF. Which
nursing action is the priority, and what is the likely diagnosis?
A. Administer aluminum hydroxide/magnesium hydroxide for suspected GERD; Inferior Wall MI.
B. Initiate the hospital's ACS protocol including oxygen, aspirin, and preparation for PCI; Inferior
Wall MI. C. Prepare for an abdominal ultrasound to rule out cholecystitis; Anterior Wall MI. D.
Administer sublingual nitroglycerin and monitor for headache; Lateral Wall MI.
Correct Answer: B. Initiate the hospital's ACS protocol including oxygen, aspirin, and
preparation for PCI; Inferior Wall MI.
