NR 235 EXAM 3 | Medical-Surgical Nursing III
Joyce University | Curriculum 2026/2027
Exam Instructions: Read each question carefully. Select the best answer for multiple-
choice items. For dosage calculations, show your work on the provided scratch paper.
Time allowed: 90 minutes.
SECTION A: CARDIOVASCULAR & RESPIRATORY DISORDERS (15
Questions)
Q1: A 68-year-old male is admitted with acute decompensated heart failure (ADHF) with
an ejection fraction of 25%. His vital signs are: BP 88/52 mmHg, HR 118 bpm, RR 28/min,
SpO₂ 88% on room air. He reports severe dyspnea and orthopnea. Which intervention
should the nurse prioritize first?
A. Administer IV furosemide 40 mg as ordered
B. Apply supplemental oxygen at 2 L/min via nasal cannula
C. Initiate continuous positive airway pressure (CPAP) at 10 cm H₂O
D. Prepare for immediate endotracheal intubation [CORRECT]
Correct Answer: D
Rationale: This patient presents with cardiogenic shock (BP 88/52, HR 118, severe
hypoxemia SpO₂ 88%) secondary to ADHF. According to the ABCs of prioritization and
Maslow's hierarchy (physiological needs), airway and breathing take precedence. The
combination of severe hypoxemia, tachypnea, and hypotension indicates impending
respiratory failure requiring definitive airway protection. While CPAP (Option C) is
appropriate for acute pulmonary edema without shock, this patient's hypotension
makes positive pressure ventilation risky without intubation and hemodynamic support.
Option A (diuretics) would worsen hypoperfusion. Option B (low-flow O₂) is insufficient
for this degree of hypoxemia. Joyce University curriculum emphasizes that when SpO₂ <
,90% with respiratory distress and hemodynamic instability, intubation precedes other
interventions.
Q2: A nurse is caring for a patient 24 hours post-myocardial infarction (STEMI) treated
with primary PCI. The patient suddenly develops jugular venous distension, muffled
heart sounds, and hypotension (BP 78/50). Which condition should the nurse suspect?
A. Cardiac tamponade [CORRECT]
B. Papillary muscle rupture
C. Ventricular septal defect
D. Free wall rupture
Correct Answer: A
Rationale: Beck's Triad (hypotension, JVD, muffled heart sounds) is pathognomonic for
cardiac tamponade, a complication of MI or cardiac procedures. This occurs due to
blood accumulation in the pericardial space compressing the heart. Option B (papillary
muscle rupture) presents with acute mitral regurgitation and pulmonary edema. Option
C (VSD) causes a new harsh holosystolic murmur and biventricular failure. Option D (free
wall rupture) causes immediate electromechanical dissociation and death. The Joyce
University curriculum highlights that recognizing Beck's Triad allows for emergency
pericardiocentesis, which is life-saving.
Q3: [SELECT ALL THAT APPLY] A patient with chronic obstructive pulmonary disease
(COPD) is prescribed tiotropium (Spiriva) and fluticasone/salmeterol (Advair). Which
teaching points should the nurse include? (Select all that apply)
A. Rinse mouth after using Advair to prevent oral candidiasis [CORRECT]
B. Use a spacer device with the Advair inhaler [CORRECT]
C. Tiotropium is a rescue inhaler for acute bronchospasm
D. Monitor for paradoxical bronchospasm after inhaler use [CORRECT]
E. Take tiotropium only when experiencing shortness of breath
Correct Answers: A, B, D
, Rationale: Fluticasone is an inhaled corticosteroid requiring mouth rinsing to prevent
thrush (A). Spacer devices improve medication deposition and reduce oropharyngeal
deposition (B). Paradoxical bronchospasm is a rare but serious adverse effect of all
inhalers requiring immediate medical attention (D). Option C is incorrect because
tiotropium is a long-acting muscarinic antagonist (LAMA) for maintenance, not rescue.
Option E is incorrect because tiotropium is dosed once daily, not PRN. The Joyce
curriculum emphasizes patient education on proper inhaler technique to ensure
therapeutic effectiveness in COPD management.
Q4: A patient with atrial fibrillation (AFib) with rapid ventricular response (RVR) is
receiving diltiazem IV bolus. The nurse notes the rhythm converting to sinus bradycardia
at 48 bpm with BP 92/60. What is the priority nursing action?
A. Continue diltiazem infusion at maintenance dose
B. Prepare to administer IV calcium gluconate [CORRECT]
C. Immediately administer atropine 0.5 mg IV
D. Increase IV fluid rate to 125 mL/hr
Correct Answer: B
Rationale: Diltiazem, a calcium channel blocker, can cause excessive AV nodal blockade
resulting in symptomatic bradycardia and hypotension. IV calcium gluconate
antagonizes calcium channel blocker effects on the heart and vascular smooth muscle.
Option A would worsen the condition. Option C (atropine) is ineffective for calcium
channel blocker overdose as the mechanism is not vagal. Option D (fluids) addresses
hypovolemia but not the underlying calcium channel blockade. Joyce University teaches
that calcium "reverses" calcium channel blocker toxicity by competing for binding sites.
Q5: [DOSAGE CALCULATION] A patient with pulmonary embolism is prescribed heparin
IV per protocol. The protocol requires an 80 units/kg bolus followed by 18 units/kg/hr
infusion. The patient weighs 176 lbs. The pharmacy supplies heparin 25,000 units in 500
mL D5W. Calculate the bolus dose in units and the infusion rate in mL/hr.
A. 6,400 units bolus; 11.5 mL/hr
B. 6,400 units bolus; 11.52 mL/hr [CORRECT]
Joyce University | Curriculum 2026/2027
Exam Instructions: Read each question carefully. Select the best answer for multiple-
choice items. For dosage calculations, show your work on the provided scratch paper.
Time allowed: 90 minutes.
SECTION A: CARDIOVASCULAR & RESPIRATORY DISORDERS (15
Questions)
Q1: A 68-year-old male is admitted with acute decompensated heart failure (ADHF) with
an ejection fraction of 25%. His vital signs are: BP 88/52 mmHg, HR 118 bpm, RR 28/min,
SpO₂ 88% on room air. He reports severe dyspnea and orthopnea. Which intervention
should the nurse prioritize first?
A. Administer IV furosemide 40 mg as ordered
B. Apply supplemental oxygen at 2 L/min via nasal cannula
C. Initiate continuous positive airway pressure (CPAP) at 10 cm H₂O
D. Prepare for immediate endotracheal intubation [CORRECT]
Correct Answer: D
Rationale: This patient presents with cardiogenic shock (BP 88/52, HR 118, severe
hypoxemia SpO₂ 88%) secondary to ADHF. According to the ABCs of prioritization and
Maslow's hierarchy (physiological needs), airway and breathing take precedence. The
combination of severe hypoxemia, tachypnea, and hypotension indicates impending
respiratory failure requiring definitive airway protection. While CPAP (Option C) is
appropriate for acute pulmonary edema without shock, this patient's hypotension
makes positive pressure ventilation risky without intubation and hemodynamic support.
Option A (diuretics) would worsen hypoperfusion. Option B (low-flow O₂) is insufficient
for this degree of hypoxemia. Joyce University curriculum emphasizes that when SpO₂ <
,90% with respiratory distress and hemodynamic instability, intubation precedes other
interventions.
Q2: A nurse is caring for a patient 24 hours post-myocardial infarction (STEMI) treated
with primary PCI. The patient suddenly develops jugular venous distension, muffled
heart sounds, and hypotension (BP 78/50). Which condition should the nurse suspect?
A. Cardiac tamponade [CORRECT]
B. Papillary muscle rupture
C. Ventricular septal defect
D. Free wall rupture
Correct Answer: A
Rationale: Beck's Triad (hypotension, JVD, muffled heart sounds) is pathognomonic for
cardiac tamponade, a complication of MI or cardiac procedures. This occurs due to
blood accumulation in the pericardial space compressing the heart. Option B (papillary
muscle rupture) presents with acute mitral regurgitation and pulmonary edema. Option
C (VSD) causes a new harsh holosystolic murmur and biventricular failure. Option D (free
wall rupture) causes immediate electromechanical dissociation and death. The Joyce
University curriculum highlights that recognizing Beck's Triad allows for emergency
pericardiocentesis, which is life-saving.
Q3: [SELECT ALL THAT APPLY] A patient with chronic obstructive pulmonary disease
(COPD) is prescribed tiotropium (Spiriva) and fluticasone/salmeterol (Advair). Which
teaching points should the nurse include? (Select all that apply)
A. Rinse mouth after using Advair to prevent oral candidiasis [CORRECT]
B. Use a spacer device with the Advair inhaler [CORRECT]
C. Tiotropium is a rescue inhaler for acute bronchospasm
D. Monitor for paradoxical bronchospasm after inhaler use [CORRECT]
E. Take tiotropium only when experiencing shortness of breath
Correct Answers: A, B, D
, Rationale: Fluticasone is an inhaled corticosteroid requiring mouth rinsing to prevent
thrush (A). Spacer devices improve medication deposition and reduce oropharyngeal
deposition (B). Paradoxical bronchospasm is a rare but serious adverse effect of all
inhalers requiring immediate medical attention (D). Option C is incorrect because
tiotropium is a long-acting muscarinic antagonist (LAMA) for maintenance, not rescue.
Option E is incorrect because tiotropium is dosed once daily, not PRN. The Joyce
curriculum emphasizes patient education on proper inhaler technique to ensure
therapeutic effectiveness in COPD management.
Q4: A patient with atrial fibrillation (AFib) with rapid ventricular response (RVR) is
receiving diltiazem IV bolus. The nurse notes the rhythm converting to sinus bradycardia
at 48 bpm with BP 92/60. What is the priority nursing action?
A. Continue diltiazem infusion at maintenance dose
B. Prepare to administer IV calcium gluconate [CORRECT]
C. Immediately administer atropine 0.5 mg IV
D. Increase IV fluid rate to 125 mL/hr
Correct Answer: B
Rationale: Diltiazem, a calcium channel blocker, can cause excessive AV nodal blockade
resulting in symptomatic bradycardia and hypotension. IV calcium gluconate
antagonizes calcium channel blocker effects on the heart and vascular smooth muscle.
Option A would worsen the condition. Option C (atropine) is ineffective for calcium
channel blocker overdose as the mechanism is not vagal. Option D (fluids) addresses
hypovolemia but not the underlying calcium channel blockade. Joyce University teaches
that calcium "reverses" calcium channel blocker toxicity by competing for binding sites.
Q5: [DOSAGE CALCULATION] A patient with pulmonary embolism is prescribed heparin
IV per protocol. The protocol requires an 80 units/kg bolus followed by 18 units/kg/hr
infusion. The patient weighs 176 lbs. The pharmacy supplies heparin 25,000 units in 500
mL D5W. Calculate the bolus dose in units and the infusion rate in mL/hr.
A. 6,400 units bolus; 11.5 mL/hr
B. 6,400 units bolus; 11.52 mL/hr [CORRECT]
