NUR 242 Exam 4 Medical-Surgical Nursing
Official Practice Exam Actual Exam 2026/2027
with Detailed Rationales | Complete Exam-Style
Questions | Pass Guaranteed – A+ Graded
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SECTION 1: ADVANCED CARDIOVASCULAR DISORDERS Q1 – Q10
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Question 1 of 50
A 74-year-old male with a 15-year history of systolic heart failure presents with sudden onset
of severe dyspnea at rest, orthopnea, and anxiety. Vital signs reveal BP 172/98, HR 124 and
irregular, RR 34, and SpO2 82% on 2 L nasal cannula. Bilateral crackles are audible to the
apices, and 3+ pitting edema is present in both lower extremities. The nurse's immediate
priority is to:
A. Administer furosemide 80 mg IV push after obtaining a BUN and creatinine
B. Apply a non-rebreather mask at 15 L/min and position the patient upright ✓ CORRECT
C. Insert a Foley catheter to monitor hourly urine output
D. Obtain a 12-lead ECG and draw a BNP level
Correct Answer: B
Rationale: In acute pulmonary edema from heart failure exacerbation, airway and oxygenation
take absolute priority over pharmacologic intervention, and placing the patient upright
reduces venous return and pulmonary congestion immediately. While furosemide is essential
for fluid removal, administering it before addressing life-threatening hypoxemia violates the
ABC priority framework, and positioning the patient upright maximizes diaphragmatic
excursion and ventilatory efficiency.
Question 2 of 50
A 58-year-old male is admitted with chest pain rated 9/10 that began 45 minutes ago while
mowing the lawn. He is diaphoretic, nauseated, and has ST-segment elevation in leads V1
through V4 on the 12-lead ECG. Vital signs are BP 148/92, HR 104, RR 22, SpO2 94%. The
emergency department physician orders aspirin 325 mg chewable, nitroglycerin 0.4 mg
sublingual, and morphine 2 mg IV. After administering the aspirin and nitroglycerin, the nurse
notes the patient's BP is now 98/58. The nurse's priority action is to:
,A. Administer the morphine 2 mg IV as ordered to reduce myocardial oxygen demand
B. Prepare the patient for immediate transfer to the cardiac catheterization lab
C. Administer a 250 mL bolus of normal saline to support preload
D. Hold the morphine and reassess the patient for further hypotension ✓ CORRECT
Correct Answer: D
Rationale: Morphine causes venodilation and can further reduce preload and blood pressure
in a hypotensive patient with an anterior STEMI, potentially worsening coronary perfusion and
delaying definitive revascularization. Although rapid cath lab transfer is the definitive
treatment, the nurse must first ensure hemodynamic stability before administering additional
medications that could cause further decompensation.
Question 3 of 50
A 66-year-old female with a history of hypertension and atrial fibrillation is admitted for
syncope. Her telemetry reveals an irregularly irregular rhythm with a ventricular rate of 154
bpm. Her BP is 104/68, she is mildly confused, and her skin is cool and clammy. The
physician orders a 150 mg amiodarone IV bolus over 10 minutes. The nurse should:
A. Prepare for synchronized cardioversion at 100-200 joules while the amiodarone infuses ✓
CORRECT
B. Administer diltiazem 20 mg IV push over 2 minutes to slow the ventricular response
C. Initiate transcutaneous pacing at a rate of 60 bpm as a backup measure
D. Increase the IV fluid rate to 125 mL/hr to improve perfusion
Correct Answer: A
Rationale: Atrial fibrillation with a rapid ventricular response in the presence of hypotension
and altered mental status constitutes an unstable tachyarrhythmia requiring immediate
synchronized cardioversion per ACLS guidelines. Diltiazem is contraindicated in unstable
patients because it can worsen hypotension and precipitate cardiovascular collapse by
further reducing cardiac output.
Question 4 of 50
A 62-year-old male post-op day 2 from coronary artery bypass grafting has a pulmonary artery
catheter in place. The waveform suddenly changes from a pulmonary artery tracing to a
respiratory variation pattern with mean pressures around 12 mmHg during inspiration, and the
patient complains of new chest pain. The nurse should:
A. Flush the catheter with 10 mL of normal saline to clear any thrombus
B. Advance the catheter 2-3 cm and reinflate the balloon to obtain a wedge tracing
C. Deflate the balloon immediately and notify the provider of catheter migration ✓ CORRECT
D. Document the finding as a normal variation and continue hourly measurements
, Correct Answer: C
Rationale: A pulmonary artery catheter showing a wedge pressure waveform with the balloon
deflated indicates distal migration and over-wedging, which places the patient at risk for
pulmonary artery rupture or infarction. Flushing the catheter could force a clot into the
pulmonary circulation or worsen vessel injury, and advancing it further would increase the risk
of perforation.
Question 5 of 50
A 55-year-old female with a history of dilated cardiomyopathy presents with fatigue,
hypotension, and oliguria. Her hemodynamic monitoring reveals arterial BP 82/56, PAOP 18
mmHg, cardiac output 3.8 L/min, and SVR 1400 dynes/sec/cm^-5. Her mixed venous oxygen
saturation is 58%. The nurse recognizes these findings are consistent with:
A. Hypovolemic shock requiring aggressive crystalloid resuscitation
B. Cardiogenic shock with volume overload requiring inotropic support ✓ CORRECT
C. Septic shock requiring broad-spectrum antibiotics and vasopressors
D. Anaphylactic shock requiring epinephrine and antihistamines
Correct Answer: B
Rationale: The hemodynamic profile of elevated pulmonary artery wedge pressure, low
cardiac output, and elevated systemic vascular resistance is classic for cardiogenic shock,
where dobutamine improves inotropy and cardiac output without significantly increasing
afterload. Volume administration would further elevate the already elevated wedge pressure
and worsen pulmonary edema, while norepinephrine would increase afterload and myocardial
oxygen demand in a failing heart.
Question 6 of 50
A 70-year-old male with chronic heart failure is prescribed sacubitril/valsartan 49/51 mg twice
daily. During medication reconciliation, the nurse notes he is also taking lisinopril 20 mg
daily, spironolactone 25 mg daily, and metoprolol 50 mg twice daily. The nurse's priority
action is to:
A. Hold the lisinopril and contact the provider before starting sacubitril/valsartan ✓ CORRECT
B. Administer all medications as ordered since they target different receptors
C. Hold the spironolactone due to the risk of dual potassium-sparing effects
D. Give the sacubitril/valsartan with lisinopril but hold the metoprolol
Correct Answer: A
Rationale: Concurrent administration of sacubitril/valsartan with an ACE inhibitor such as
lisinopril increases the risk of serious angioedema and hypotension, requiring a 36-hour
washout period between the two drug classes. Spironolactone can be continued with an ARNI
under monitoring, but the ACE inhibitor must be discontinued before initiation.
Official Practice Exam Actual Exam 2026/2027
with Detailed Rationales | Complete Exam-Style
Questions | Pass Guaranteed – A+ Graded
══════════════════════════════════════
SECTION 1: ADVANCED CARDIOVASCULAR DISORDERS Q1 – Q10
══════════════════════════════════════
Question 1 of 50
A 74-year-old male with a 15-year history of systolic heart failure presents with sudden onset
of severe dyspnea at rest, orthopnea, and anxiety. Vital signs reveal BP 172/98, HR 124 and
irregular, RR 34, and SpO2 82% on 2 L nasal cannula. Bilateral crackles are audible to the
apices, and 3+ pitting edema is present in both lower extremities. The nurse's immediate
priority is to:
A. Administer furosemide 80 mg IV push after obtaining a BUN and creatinine
B. Apply a non-rebreather mask at 15 L/min and position the patient upright ✓ CORRECT
C. Insert a Foley catheter to monitor hourly urine output
D. Obtain a 12-lead ECG and draw a BNP level
Correct Answer: B
Rationale: In acute pulmonary edema from heart failure exacerbation, airway and oxygenation
take absolute priority over pharmacologic intervention, and placing the patient upright
reduces venous return and pulmonary congestion immediately. While furosemide is essential
for fluid removal, administering it before addressing life-threatening hypoxemia violates the
ABC priority framework, and positioning the patient upright maximizes diaphragmatic
excursion and ventilatory efficiency.
Question 2 of 50
A 58-year-old male is admitted with chest pain rated 9/10 that began 45 minutes ago while
mowing the lawn. He is diaphoretic, nauseated, and has ST-segment elevation in leads V1
through V4 on the 12-lead ECG. Vital signs are BP 148/92, HR 104, RR 22, SpO2 94%. The
emergency department physician orders aspirin 325 mg chewable, nitroglycerin 0.4 mg
sublingual, and morphine 2 mg IV. After administering the aspirin and nitroglycerin, the nurse
notes the patient's BP is now 98/58. The nurse's priority action is to:
,A. Administer the morphine 2 mg IV as ordered to reduce myocardial oxygen demand
B. Prepare the patient for immediate transfer to the cardiac catheterization lab
C. Administer a 250 mL bolus of normal saline to support preload
D. Hold the morphine and reassess the patient for further hypotension ✓ CORRECT
Correct Answer: D
Rationale: Morphine causes venodilation and can further reduce preload and blood pressure
in a hypotensive patient with an anterior STEMI, potentially worsening coronary perfusion and
delaying definitive revascularization. Although rapid cath lab transfer is the definitive
treatment, the nurse must first ensure hemodynamic stability before administering additional
medications that could cause further decompensation.
Question 3 of 50
A 66-year-old female with a history of hypertension and atrial fibrillation is admitted for
syncope. Her telemetry reveals an irregularly irregular rhythm with a ventricular rate of 154
bpm. Her BP is 104/68, she is mildly confused, and her skin is cool and clammy. The
physician orders a 150 mg amiodarone IV bolus over 10 minutes. The nurse should:
A. Prepare for synchronized cardioversion at 100-200 joules while the amiodarone infuses ✓
CORRECT
B. Administer diltiazem 20 mg IV push over 2 minutes to slow the ventricular response
C. Initiate transcutaneous pacing at a rate of 60 bpm as a backup measure
D. Increase the IV fluid rate to 125 mL/hr to improve perfusion
Correct Answer: A
Rationale: Atrial fibrillation with a rapid ventricular response in the presence of hypotension
and altered mental status constitutes an unstable tachyarrhythmia requiring immediate
synchronized cardioversion per ACLS guidelines. Diltiazem is contraindicated in unstable
patients because it can worsen hypotension and precipitate cardiovascular collapse by
further reducing cardiac output.
Question 4 of 50
A 62-year-old male post-op day 2 from coronary artery bypass grafting has a pulmonary artery
catheter in place. The waveform suddenly changes from a pulmonary artery tracing to a
respiratory variation pattern with mean pressures around 12 mmHg during inspiration, and the
patient complains of new chest pain. The nurse should:
A. Flush the catheter with 10 mL of normal saline to clear any thrombus
B. Advance the catheter 2-3 cm and reinflate the balloon to obtain a wedge tracing
C. Deflate the balloon immediately and notify the provider of catheter migration ✓ CORRECT
D. Document the finding as a normal variation and continue hourly measurements
, Correct Answer: C
Rationale: A pulmonary artery catheter showing a wedge pressure waveform with the balloon
deflated indicates distal migration and over-wedging, which places the patient at risk for
pulmonary artery rupture or infarction. Flushing the catheter could force a clot into the
pulmonary circulation or worsen vessel injury, and advancing it further would increase the risk
of perforation.
Question 5 of 50
A 55-year-old female with a history of dilated cardiomyopathy presents with fatigue,
hypotension, and oliguria. Her hemodynamic monitoring reveals arterial BP 82/56, PAOP 18
mmHg, cardiac output 3.8 L/min, and SVR 1400 dynes/sec/cm^-5. Her mixed venous oxygen
saturation is 58%. The nurse recognizes these findings are consistent with:
A. Hypovolemic shock requiring aggressive crystalloid resuscitation
B. Cardiogenic shock with volume overload requiring inotropic support ✓ CORRECT
C. Septic shock requiring broad-spectrum antibiotics and vasopressors
D. Anaphylactic shock requiring epinephrine and antihistamines
Correct Answer: B
Rationale: The hemodynamic profile of elevated pulmonary artery wedge pressure, low
cardiac output, and elevated systemic vascular resistance is classic for cardiogenic shock,
where dobutamine improves inotropy and cardiac output without significantly increasing
afterload. Volume administration would further elevate the already elevated wedge pressure
and worsen pulmonary edema, while norepinephrine would increase afterload and myocardial
oxygen demand in a failing heart.
Question 6 of 50
A 70-year-old male with chronic heart failure is prescribed sacubitril/valsartan 49/51 mg twice
daily. During medication reconciliation, the nurse notes he is also taking lisinopril 20 mg
daily, spironolactone 25 mg daily, and metoprolol 50 mg twice daily. The nurse's priority
action is to:
A. Hold the lisinopril and contact the provider before starting sacubitril/valsartan ✓ CORRECT
B. Administer all medications as ordered since they target different receptors
C. Hold the spironolactone due to the risk of dual potassium-sparing effects
D. Give the sacubitril/valsartan with lisinopril but hold the metoprolol
Correct Answer: A
Rationale: Concurrent administration of sacubitril/valsartan with an ACE inhibitor such as
lisinopril increases the risk of serious angioedema and hypotension, requiring a 36-hour
washout period between the two drug classes. Spironolactone can be continued with an ARNI
under monitoring, but the ACE inhibitor must be discontinued before initiation.
