NURS 681 Exam 2026 Expert Questions & Correct
Answers with Detailed Rationales by Alex R. Kasyan |
NURS 681 Complete Latest Fall 2025/26 - West Coast
University
1. A patient with a history of chronic heart failure (NYHA class III) and atrial fibrillation is being
managed with digoxin, warfarin, and furosemide. Recently, amiodarone was added for rhythm
control. Which of the following best describes the expected pharmacokinetic interaction and
necessary monitoring adjustment?
A. Amiodarone increases the hepatic metabolism of warfarin, requiring a 50% dose increase of warfarin.
B. Amiodarone displaces digoxin from tissue binding sites, increasing serum digoxin level; reduce digoxin dose
by 30-50% and monitor levels.
C. Amiodarone is a potent CYP3A4 inducer, decreasing furosemide efficacy; increase furosemide dose.
D. Amiodarone has no significant interaction with digoxin, but warfarin levels should be monitored due to
protein binding displacement.
Answer: B
2. A patient with type 2 diabetes and chronic kidney disease (eGFR 35 mL/min/1.73 m²) is
currently on metformin and insulin glargine. Glycemic control remains suboptimal (HbA1c 8.9%).
Which of the following agents would be MOST appropriate to add as a third-line therapy,
considering renal function?
A. Canagliflozin, as SGLT2 inhibitors are preferred in CKD regardless of eGFR.
B. Liraglutide, as GLP-1 receptor agonists are safe and beneficial in CKD with eGFR above 30 mL/min.
C. Pioglitazone, as it is not renally excreted and can be used without dose adjustment.
D. Saxagliptin, as DPP-4 inhibitors are safe in all stages of CKD.
Answer: B
3. Which of the following mechanisms best explains the development of metabolic alkalosis in a
patient receiving high-dose loop diuretics for acute decompensated heart failure?
A. Increased distal sodium delivery enhances potassium secretion, leading to hypokalemia and intracellular shift
of hydrogen ions.
B. Loop diuretics directly inhibit the renal H+/K+ ATPase, reducing acid excretion.
C. Contraction alkalosis from rapid reduction of extracellular fluid volume without proportional loss of
bicarbonate.
D. Increased aldosterone secretion secondary to volume depletion stimulates hydrogen ion secretion in the
collecting duct.
Answer: A
Page 1
,4. A patient with a history of recurrent Clostridioides difficile infection (three episodes in the past
year) presents with another episode confirmed by stool PCR. The patient has no contraindications
to fecal microbiota transplantation (FMT). Which of the following is the most appropriate next
step in management according to current IDSA guidelines?
A. Initiate a prolonged tapered course of vancomycin (e.g., 125 mg four times daily for 10 days, then taper over
6 weeks).
B. Administer fidaxomicin 200 mg twice daily for 10 days, followed by FMT if recurrence occurs.
C. Proceed directly to fecal microbiota transplantation via colonoscopy after a standard course of vancomycin.
D. Treat with metronidazole 500 mg three times daily for 14 days and monitor for response.
Answer: A
5. A patient with a history of opioid use disorder (OUD) is being initiated on
buprenorphine/naloxone for maintenance therapy. The patient reports last using heroin 12 hours
ago. Which of the following best describes the appropriate induction strategy and expected
outcome?
A. Administer buprenorphine/naloxone immediately; the naloxone component will precipitate withdrawal if the
patient is still intoxicated.
B. Wait until the patient exhibits moderate withdrawal (Clinical Opiate Withdrawal Scale [COWS] 8) before
administering the first dose; buprenorphine may then precipitate mild withdrawal that resolves within 24 hours.
C. Begin with a low dose of buprenorphine alone (without naloxone) and titrate upward over 3 days to avoid
precipitated withdrawal.
D. Initiate buprenorphine/naloxone only after 72 hours of abstinence to ensure no residual opioid effect;
otherwise, severe precipitated withdrawal is likely.
Answer: B
6. A patient with a history of bipolar I disorder is currently stable on lithium carbonate 900
mg/day. Routine labs show a serum lithium level of 1.2 mEq/L (therapeutic range 0.6-1.2). The
patient is diagnosed with hypertension and started on hydrochlorothiazide 25 mg daily. After one
week, the patient presents with confusion, tremor, and ataxia. Which of the following is the most
likely cause?
A. Hydrochlorothiazide increases lithium reabsorption in the proximal tubule, leading to lithium toxicity.
B. Hydrochlorothiazide competes with lithium for secretion in the distal tubule, raising lithium levels.
C. Hydrochlorothiazide causes volume depletion, which reduces lithium clearance and increases serum lithium
into the toxic range.
D. Hydrochlorothiazide induces CYP3A4, increasing lithium metabolism to a toxic metabolite.
Answer: C
7. A patient with moderate persistent asthma is currently on low-dose inhaled corticosteroid (ICS)
and as-needed short-acting beta agonist (SABA). Despite good adherence, the patient requires
SABA more than twice weekly and has nocturnal awakenings 3 times per month. According to the
2024 GINA guidelines, which of the following is the preferred step-up therapy?
A. Increase ICS to medium dose and continue as-needed SABA.
B. Add a long-acting muscarinic antagonist (LAMA) such as tiotropium.
C. Switch to low-dose ICS-formoterol as maintenance and reliever therapy (MART).
Page 2
,D. Add a leukotriene receptor antagonist (LTRA) to low-dose ICS.
Answer: C
8. A patient with a history of recurrent major depressive disorder is started on venlafaxine
extended-release 75 mg daily. After 4 weeks, the dose is increased to 150 mg daily. Two weeks later,
the patient reports feeling 'wired,' with a decreased need for sleep, rapid speech, and grandiose
plans. Which of the following is the most appropriate next step?
A. Increase venlafaxine to 225 mg daily to achieve full therapeutic effect.
B. Discontinue venlafaxine immediately and start a mood stabilizer such as lithium.
C. Add a low-dose atypical antipsychotic such as aripiprazole to augment antidepressant effect.
D. Taper venlafaxine and initiate a mood stabilizer, as this likely represents a switch to mania.
Answer: D
9. A patient with a history of cirrhosis (Child-Pugh class B) and atrial fibrillation is being
considered for anticoagulation. The patient's CHA2DS2-VASc score is 4, and HAS-BLED score is
3. Which of the following anticoagulant strategies is most appropriate?
A. Apixaban 5 mg twice daily, as it has the best safety profile in cirrhosis.
B. Warfarin with a target INR of 2-3, as it is the only agent with reversal agents.
C. Edoxaban 60 mg daily, as it is not metabolized by the liver.
D. Avoid anticoagulation due to high bleeding risk and consider left atrial appendage closure.
Answer: D
10. A patient with a history of hypertension and type 2 diabetes is started on lisinopril 10 mg daily.
Two weeks later, the patient develops angioedema involving the lips and tongue. Which of the
following best describes the underlying mechanism and appropriate alternative therapy?
A. Lisinopril inhibits bradykinin degradation, leading to accumulation; switch to an angiotensin receptor
blocker (ARB) such as losartan.
B. Lisinopril causes direct mast cell degranulation; switch to a calcium channel blocker.
C. Lisinopril increases histamine release via ACE inhibition; switch to a beta-blocker.
D. Lisinopril induces IgE-mediated hypersensitivity; switch to a direct renin inhibitor such as aliskiren.
Answer: A
11. A patient with a history of chronic kidney disease (stage 4) is admitted with severe dyspnea and
orthopnea. Vital signs: BP 178/95, HR 110, RR 28, SpO2 89% on room air. On auscultation,
crackles in both lung bases and an S3 gallop are noted. The patient is anuric for the past 12 hours.
Current medications include lisinopril and furosemide. Which intervention should the nurse
prioritize?
A. Administer intravenous furosemide 80 mg bolus
B. Initiate continuous venovenous hemofiltration (CVVH) immediately
C. Administer intravenous sodium nitroprusside for afterload reduction
D. Prepare for emergent endotracheal intubation and mechanical ventilation
Answer: A
Page 3
, 12. A research study examines the effect of a new nurse-led discharge intervention on 30-day
readmission rates for patients with heart failure. The study uses a quasi-experimental design with
a historical control group. Which threat to internal validity is most concerning in this design?
A. Selection bias due to non-random assignment
B. Maturation effect from changes over time
C. History effect from concurrent changes in standard care
D. Testing effect due to repeated measurements
Answer: C
13. A nurse is evaluating a patient with a central venous catheter (CVC) who develops sudden
onset of dyspnea, chest pain, and hypotension. The nurse suspects an air embolism. Which action
should the nurse take first?
A. Place the patient in Trendelenburg position on the left side
B. Administer 100% oxygen via non-rebreather mask
C. Clamp the CVC immediately and notify the provider
D. Prepare for emergent chest tube insertion
Answer: A
14. A patient with septic shock is receiving norepinephrine via central line at 20 mcg/min. The
mean arterial pressure (MAP) is 58 mm Hg. The provider orders a second vasopressor,
vasopressin, to be started at 0.04 units/min. The nurse understands that the rationale for adding
vasopressin is:
A. To reverse the beta-adrenergic effects of norepinephrine
B. To provide a synergistic effect by targeting different receptors
C. To replace the relative vasopressin deficiency seen in septic shock
D. To allow for rapid weaning of norepinephrine
Answer: C
15. A nurse is caring for a patient with acute respiratory distress syndrome (ARDS) who is on
volume-controlled ventilation. The plateau pressure is 32 cm H2O, and the tidal volume is 6 mL/kg
predicted body weight. The arterial blood gas shows pH 7.25, PaCO2 55 mm Hg, PaO2 65 mm Hg
on FiO2 0.6. Which adjustment should the nurse anticipate?
A. Increase tidal volume to 8 mL/kg to improve ventilation
B. Increase PEEP to improve oxygenation and reduce FiO2
C. Increase respiratory rate to 35 breaths/min
D. Switch to pressure-controlled ventilation to lower plateau pressure
Answer: B
16. A patient with a traumatic brain injury (TBI) has an intracranial pressure (ICP) monitor
reading of 22 mm Hg. The nurse notes the patient is posturing and the pupils are sluggish. Which
intervention should the nurse implement first?
A. Administer mannitol 0.5 g/kg IV over 30 minutes
Page 4
Answers with Detailed Rationales by Alex R. Kasyan |
NURS 681 Complete Latest Fall 2025/26 - West Coast
University
1. A patient with a history of chronic heart failure (NYHA class III) and atrial fibrillation is being
managed with digoxin, warfarin, and furosemide. Recently, amiodarone was added for rhythm
control. Which of the following best describes the expected pharmacokinetic interaction and
necessary monitoring adjustment?
A. Amiodarone increases the hepatic metabolism of warfarin, requiring a 50% dose increase of warfarin.
B. Amiodarone displaces digoxin from tissue binding sites, increasing serum digoxin level; reduce digoxin dose
by 30-50% and monitor levels.
C. Amiodarone is a potent CYP3A4 inducer, decreasing furosemide efficacy; increase furosemide dose.
D. Amiodarone has no significant interaction with digoxin, but warfarin levels should be monitored due to
protein binding displacement.
Answer: B
2. A patient with type 2 diabetes and chronic kidney disease (eGFR 35 mL/min/1.73 m²) is
currently on metformin and insulin glargine. Glycemic control remains suboptimal (HbA1c 8.9%).
Which of the following agents would be MOST appropriate to add as a third-line therapy,
considering renal function?
A. Canagliflozin, as SGLT2 inhibitors are preferred in CKD regardless of eGFR.
B. Liraglutide, as GLP-1 receptor agonists are safe and beneficial in CKD with eGFR above 30 mL/min.
C. Pioglitazone, as it is not renally excreted and can be used without dose adjustment.
D. Saxagliptin, as DPP-4 inhibitors are safe in all stages of CKD.
Answer: B
3. Which of the following mechanisms best explains the development of metabolic alkalosis in a
patient receiving high-dose loop diuretics for acute decompensated heart failure?
A. Increased distal sodium delivery enhances potassium secretion, leading to hypokalemia and intracellular shift
of hydrogen ions.
B. Loop diuretics directly inhibit the renal H+/K+ ATPase, reducing acid excretion.
C. Contraction alkalosis from rapid reduction of extracellular fluid volume without proportional loss of
bicarbonate.
D. Increased aldosterone secretion secondary to volume depletion stimulates hydrogen ion secretion in the
collecting duct.
Answer: A
Page 1
,4. A patient with a history of recurrent Clostridioides difficile infection (three episodes in the past
year) presents with another episode confirmed by stool PCR. The patient has no contraindications
to fecal microbiota transplantation (FMT). Which of the following is the most appropriate next
step in management according to current IDSA guidelines?
A. Initiate a prolonged tapered course of vancomycin (e.g., 125 mg four times daily for 10 days, then taper over
6 weeks).
B. Administer fidaxomicin 200 mg twice daily for 10 days, followed by FMT if recurrence occurs.
C. Proceed directly to fecal microbiota transplantation via colonoscopy after a standard course of vancomycin.
D. Treat with metronidazole 500 mg three times daily for 14 days and monitor for response.
Answer: A
5. A patient with a history of opioid use disorder (OUD) is being initiated on
buprenorphine/naloxone for maintenance therapy. The patient reports last using heroin 12 hours
ago. Which of the following best describes the appropriate induction strategy and expected
outcome?
A. Administer buprenorphine/naloxone immediately; the naloxone component will precipitate withdrawal if the
patient is still intoxicated.
B. Wait until the patient exhibits moderate withdrawal (Clinical Opiate Withdrawal Scale [COWS] 8) before
administering the first dose; buprenorphine may then precipitate mild withdrawal that resolves within 24 hours.
C. Begin with a low dose of buprenorphine alone (without naloxone) and titrate upward over 3 days to avoid
precipitated withdrawal.
D. Initiate buprenorphine/naloxone only after 72 hours of abstinence to ensure no residual opioid effect;
otherwise, severe precipitated withdrawal is likely.
Answer: B
6. A patient with a history of bipolar I disorder is currently stable on lithium carbonate 900
mg/day. Routine labs show a serum lithium level of 1.2 mEq/L (therapeutic range 0.6-1.2). The
patient is diagnosed with hypertension and started on hydrochlorothiazide 25 mg daily. After one
week, the patient presents with confusion, tremor, and ataxia. Which of the following is the most
likely cause?
A. Hydrochlorothiazide increases lithium reabsorption in the proximal tubule, leading to lithium toxicity.
B. Hydrochlorothiazide competes with lithium for secretion in the distal tubule, raising lithium levels.
C. Hydrochlorothiazide causes volume depletion, which reduces lithium clearance and increases serum lithium
into the toxic range.
D. Hydrochlorothiazide induces CYP3A4, increasing lithium metabolism to a toxic metabolite.
Answer: C
7. A patient with moderate persistent asthma is currently on low-dose inhaled corticosteroid (ICS)
and as-needed short-acting beta agonist (SABA). Despite good adherence, the patient requires
SABA more than twice weekly and has nocturnal awakenings 3 times per month. According to the
2024 GINA guidelines, which of the following is the preferred step-up therapy?
A. Increase ICS to medium dose and continue as-needed SABA.
B. Add a long-acting muscarinic antagonist (LAMA) such as tiotropium.
C. Switch to low-dose ICS-formoterol as maintenance and reliever therapy (MART).
Page 2
,D. Add a leukotriene receptor antagonist (LTRA) to low-dose ICS.
Answer: C
8. A patient with a history of recurrent major depressive disorder is started on venlafaxine
extended-release 75 mg daily. After 4 weeks, the dose is increased to 150 mg daily. Two weeks later,
the patient reports feeling 'wired,' with a decreased need for sleep, rapid speech, and grandiose
plans. Which of the following is the most appropriate next step?
A. Increase venlafaxine to 225 mg daily to achieve full therapeutic effect.
B. Discontinue venlafaxine immediately and start a mood stabilizer such as lithium.
C. Add a low-dose atypical antipsychotic such as aripiprazole to augment antidepressant effect.
D. Taper venlafaxine and initiate a mood stabilizer, as this likely represents a switch to mania.
Answer: D
9. A patient with a history of cirrhosis (Child-Pugh class B) and atrial fibrillation is being
considered for anticoagulation. The patient's CHA2DS2-VASc score is 4, and HAS-BLED score is
3. Which of the following anticoagulant strategies is most appropriate?
A. Apixaban 5 mg twice daily, as it has the best safety profile in cirrhosis.
B. Warfarin with a target INR of 2-3, as it is the only agent with reversal agents.
C. Edoxaban 60 mg daily, as it is not metabolized by the liver.
D. Avoid anticoagulation due to high bleeding risk and consider left atrial appendage closure.
Answer: D
10. A patient with a history of hypertension and type 2 diabetes is started on lisinopril 10 mg daily.
Two weeks later, the patient develops angioedema involving the lips and tongue. Which of the
following best describes the underlying mechanism and appropriate alternative therapy?
A. Lisinopril inhibits bradykinin degradation, leading to accumulation; switch to an angiotensin receptor
blocker (ARB) such as losartan.
B. Lisinopril causes direct mast cell degranulation; switch to a calcium channel blocker.
C. Lisinopril increases histamine release via ACE inhibition; switch to a beta-blocker.
D. Lisinopril induces IgE-mediated hypersensitivity; switch to a direct renin inhibitor such as aliskiren.
Answer: A
11. A patient with a history of chronic kidney disease (stage 4) is admitted with severe dyspnea and
orthopnea. Vital signs: BP 178/95, HR 110, RR 28, SpO2 89% on room air. On auscultation,
crackles in both lung bases and an S3 gallop are noted. The patient is anuric for the past 12 hours.
Current medications include lisinopril and furosemide. Which intervention should the nurse
prioritize?
A. Administer intravenous furosemide 80 mg bolus
B. Initiate continuous venovenous hemofiltration (CVVH) immediately
C. Administer intravenous sodium nitroprusside for afterload reduction
D. Prepare for emergent endotracheal intubation and mechanical ventilation
Answer: A
Page 3
, 12. A research study examines the effect of a new nurse-led discharge intervention on 30-day
readmission rates for patients with heart failure. The study uses a quasi-experimental design with
a historical control group. Which threat to internal validity is most concerning in this design?
A. Selection bias due to non-random assignment
B. Maturation effect from changes over time
C. History effect from concurrent changes in standard care
D. Testing effect due to repeated measurements
Answer: C
13. A nurse is evaluating a patient with a central venous catheter (CVC) who develops sudden
onset of dyspnea, chest pain, and hypotension. The nurse suspects an air embolism. Which action
should the nurse take first?
A. Place the patient in Trendelenburg position on the left side
B. Administer 100% oxygen via non-rebreather mask
C. Clamp the CVC immediately and notify the provider
D. Prepare for emergent chest tube insertion
Answer: A
14. A patient with septic shock is receiving norepinephrine via central line at 20 mcg/min. The
mean arterial pressure (MAP) is 58 mm Hg. The provider orders a second vasopressor,
vasopressin, to be started at 0.04 units/min. The nurse understands that the rationale for adding
vasopressin is:
A. To reverse the beta-adrenergic effects of norepinephrine
B. To provide a synergistic effect by targeting different receptors
C. To replace the relative vasopressin deficiency seen in septic shock
D. To allow for rapid weaning of norepinephrine
Answer: C
15. A nurse is caring for a patient with acute respiratory distress syndrome (ARDS) who is on
volume-controlled ventilation. The plateau pressure is 32 cm H2O, and the tidal volume is 6 mL/kg
predicted body weight. The arterial blood gas shows pH 7.25, PaCO2 55 mm Hg, PaO2 65 mm Hg
on FiO2 0.6. Which adjustment should the nurse anticipate?
A. Increase tidal volume to 8 mL/kg to improve ventilation
B. Increase PEEP to improve oxygenation and reduce FiO2
C. Increase respiratory rate to 35 breaths/min
D. Switch to pressure-controlled ventilation to lower plateau pressure
Answer: B
16. A patient with a traumatic brain injury (TBI) has an intracranial pressure (ICP) monitor
reading of 22 mm Hg. The nurse notes the patient is posturing and the pupils are sluggish. Which
intervention should the nurse implement first?
A. Administer mannitol 0.5 g/kg IV over 30 minutes
Page 4
