NUR 265 Exam 1 Advanced Concepts Of Medical-
Surgical Nursing | 150 Exam Practice Questions With
Expert Rationales | 2026/2027 Updates
Question 1.
A patient admitted with acute decompensated heart failure has a blood pressure of 88/52
mmHg, heart rate of 118 bpm, and urine output of 15 mL/hr. The nurse notes crackles
bilaterally and cool, clammy skin. Which intervention should the nurse anticipate first?
• A. Initiate dobutamine infusion per protocol.
• B. Administer IV furosemide 80 mg push.
• C. Begin continuous positive airway pressure (CPAP).
• D. Place the patient in high-Fowler's position and prepare for intubation.
Correct Answer: A
Rationale:
The patient presents with cardiogenic shock (hypotension, tachycardia, low urine output, cool
clammy skin) secondary to acute decompensated heart failure. Inotropic support with
dobutamine is indicated to improve cardiac contractility and restore perfusion before other
interventions.
Option B is incorrect: Furosemide is contraindicated in cardiogenic shock because it reduces
preload and can worsen hypotension by further decreasing circulating volume.
Option C is incorrect: While CPAP may eventually be needed for pulmonary edema, the
immediate life-threatening issue is inadequate tissue perfusion from cardiogenic shock, which
must be addressed first.
Option D is incorrect: High-Fowler's position is appropriate, but intubation is not the first
intervention; restoring cardiac output with inotropic support takes priority.
Question 2.
A patient with ST-elevation myocardial infarction (STEMI) is receiving a heparin infusion. The
nurse notes the patient's aPTT is 110 seconds. Which action is most appropriate?
• A. Continue the infusion at the current rate.
• B. Hold the infusion for 1 hour and recheck the aPTT.
• C. Reduce the infusion rate per protocol and recheck aPTT in 4 hours.
• D. Administer protamine sulfate immediately.
,Correct Answer: C
Rationale:
An aPTT of 110 seconds is above the therapeutic range of 60-80 seconds (or 1.5-2.5 times
control). The nurse should reduce the heparin infusion rate according to the institution's
protocol and recheck the aPTT to prevent bleeding complications while maintaining
anticoagulation.
Option A is incorrect: Continuing the current rate places the patient at increased risk for
bleeding, including intracranial hemorrhage and gastrointestinal bleeding.
Option B is incorrect: Holding the infusion for a full hour is excessive and may allow clot
formation; a rate reduction per protocol is the standard intervention for a supratherapeutic
aPTT.
Option D is incorrect: Protamine sulfate is the antidote for heparin overdose and is reserved for
severe bleeding or life-threatening hemorrhage, not for an elevated aPTT without bleeding.
Question 3.
A patient with infective endocarditis develops sudden severe dyspnea, tachypnea, and
petechiae on the chest. The nurse auscultates a new loud holosystolic murmur at the left
sternal border. Which complication should the nurse suspect?
• A. Acute mitral regurgitation from ruptured chordae tendineae.
• B. Tricuspid valve vegetation embolization to the lungs.
• C. Septic emboli causing acute respiratory distress syndrome.
• D. Acute ventricular septal defect from myocardial abscess rupture.
Correct Answer: D
Rationale:
A new loud holosystolic murmur at the left sternal border in a patient with infective endocarditis
suggests rupture of a myocardial abscess into the interventricular septum, creating an acute
ventricular septal defect. This is a catastrophic complication requiring emergent surgical
intervention.
Option A is incorrect: Mitral regurgitation from ruptured chordae tendineae produces a
holosystolic murmur but it radiates to the axilla, not the left sternal border.
Option B is incorrect: Tricuspid vegetation embolization would cause pulmonary embolism
symptoms but would not produce a new holosystolic murmur at the left sternal border.
,Option C is incorrect: ARDS from septic emboli would cause respiratory distress but does not
explain the new cardiac murmur.
Question 4.
A patient with hypertrophic cardiomyopathy (HCM) suddenly collapses in the hallway. The
nurse finds the patient unresponsive, pulseless, and apneic. Which intervention should the
nurse prioritize?
• A. Begin high-quality CPR with emphasis on rapid, deep compressions.
• B. Deliver a precordial thump and check for a response.
• C. Administer amiodarone 300 mg IV push immediately.
• D. Place the patient in the left lateral decubitus position.
Correct Answer: A
Rationale:
For a patient with HCM who suffers sudden cardiac arrest, immediate high-quality CPR is the
priority. HCM patients are at risk for ventricular fibrillation due to arrhythmogenic substrate;
CPR maintains cerebral and coronary perfusion until defibrillation can be performed.
Option B is incorrect: A precordial thump is only considered in witnessed, monitored arrests
when a defibrillator is not immediately available; it is not a substitute for CPR.
Option C is incorrect: Amiodarone is given for refractory ventricular fibrillation or pulseless VT
after defibrillation attempts, not as a first intervention in pulseless arrest.
Option D is incorrect: Left lateral decubitus position is used for pregnant patients to relieve
aortocaval compression and has no role in cardiac arrest management.
Question 5.
A patient with aortic dissection presents with tearing chest pain radiating to the back. Blood
pressure is 190/110 mmHg in the right arm and 140/88 mmHg in the left arm. Which
medication should the nurse prepare to administer first?
• A. IV nitroglycerin infusion.
• B. IV esmolol bolus followed by infusion.
• C. IV hydralazine push.
• D. Sublingual nifedipine.
Correct Answer: B
, Rationale:
Aortic dissection requires immediate reduction of shear stress on the aortic wall by lowering
heart rate and blood pressure. Esmolol, a short-acting beta-blocker, is the first-line agent
because it reduces both heart rate and contractility (dP/dt), which decreases aortic wall stress.
Vasodilators alone can increase shear stress by causing reflex tachycardia.
Option A is incorrect: Nitroglycerin primarily causes venodilation and can cause reflex
tachycardia, increasing aortic wall shear stress without beta-blockade.
Option C is incorrect: Hydralazine causes direct arterial vasodilation with significant reflex
tachycardia, which is dangerous in aortic dissection as it increases dP/dt and worsens dissection
propagation.
Option D is incorrect: Sublingual nifedipine causes rapid unpredictable blood pressure drops
and reflex tachycardia; it is contraindicated in aortic dissection.
Question 6.
A patient with a permanent pacemaker reports dizziness and syncope. Telemetry shows
intermittent failure to capture. The nurse checks the pacemaker threshold and notes it is 4.5
mA with the output set at 5.0 mA. Which action is most appropriate?
• A. Increase the pacemaker output to 7.0 mA.
• B. Decrease the sensitivity to make the pacemaker less sensitive.
• C. Replace the pacemaker battery immediately.
• D. Administer atropine 0.5 mg IV push.
Correct Answer: A
Rationale:
The pacing threshold is 4.5 mA with an output of 5.0 mA, leaving only a 0.5 mA safety margin.
The standard safety margin is at least twice the threshold or a minimum of 2.0 mA above
threshold. Increasing the output to 7.0 mA restores an adequate safety margin and should
resolve the failure to capture.
Option B is incorrect: Adjusting sensitivity addresses failure to sense (undersensing or
oversensing), not failure to capture. The problem described is failure to capture, which is an
output issue.
Option C is incorrect: Battery replacement is indicated by battery depletion indicators (elective
replacement indicator), not by elevated pacing thresholds, which indicate lead issues or tissue
changes at the electrode interface.
Surgical Nursing | 150 Exam Practice Questions With
Expert Rationales | 2026/2027 Updates
Question 1.
A patient admitted with acute decompensated heart failure has a blood pressure of 88/52
mmHg, heart rate of 118 bpm, and urine output of 15 mL/hr. The nurse notes crackles
bilaterally and cool, clammy skin. Which intervention should the nurse anticipate first?
• A. Initiate dobutamine infusion per protocol.
• B. Administer IV furosemide 80 mg push.
• C. Begin continuous positive airway pressure (CPAP).
• D. Place the patient in high-Fowler's position and prepare for intubation.
Correct Answer: A
Rationale:
The patient presents with cardiogenic shock (hypotension, tachycardia, low urine output, cool
clammy skin) secondary to acute decompensated heart failure. Inotropic support with
dobutamine is indicated to improve cardiac contractility and restore perfusion before other
interventions.
Option B is incorrect: Furosemide is contraindicated in cardiogenic shock because it reduces
preload and can worsen hypotension by further decreasing circulating volume.
Option C is incorrect: While CPAP may eventually be needed for pulmonary edema, the
immediate life-threatening issue is inadequate tissue perfusion from cardiogenic shock, which
must be addressed first.
Option D is incorrect: High-Fowler's position is appropriate, but intubation is not the first
intervention; restoring cardiac output with inotropic support takes priority.
Question 2.
A patient with ST-elevation myocardial infarction (STEMI) is receiving a heparin infusion. The
nurse notes the patient's aPTT is 110 seconds. Which action is most appropriate?
• A. Continue the infusion at the current rate.
• B. Hold the infusion for 1 hour and recheck the aPTT.
• C. Reduce the infusion rate per protocol and recheck aPTT in 4 hours.
• D. Administer protamine sulfate immediately.
,Correct Answer: C
Rationale:
An aPTT of 110 seconds is above the therapeutic range of 60-80 seconds (or 1.5-2.5 times
control). The nurse should reduce the heparin infusion rate according to the institution's
protocol and recheck the aPTT to prevent bleeding complications while maintaining
anticoagulation.
Option A is incorrect: Continuing the current rate places the patient at increased risk for
bleeding, including intracranial hemorrhage and gastrointestinal bleeding.
Option B is incorrect: Holding the infusion for a full hour is excessive and may allow clot
formation; a rate reduction per protocol is the standard intervention for a supratherapeutic
aPTT.
Option D is incorrect: Protamine sulfate is the antidote for heparin overdose and is reserved for
severe bleeding or life-threatening hemorrhage, not for an elevated aPTT without bleeding.
Question 3.
A patient with infective endocarditis develops sudden severe dyspnea, tachypnea, and
petechiae on the chest. The nurse auscultates a new loud holosystolic murmur at the left
sternal border. Which complication should the nurse suspect?
• A. Acute mitral regurgitation from ruptured chordae tendineae.
• B. Tricuspid valve vegetation embolization to the lungs.
• C. Septic emboli causing acute respiratory distress syndrome.
• D. Acute ventricular septal defect from myocardial abscess rupture.
Correct Answer: D
Rationale:
A new loud holosystolic murmur at the left sternal border in a patient with infective endocarditis
suggests rupture of a myocardial abscess into the interventricular septum, creating an acute
ventricular septal defect. This is a catastrophic complication requiring emergent surgical
intervention.
Option A is incorrect: Mitral regurgitation from ruptured chordae tendineae produces a
holosystolic murmur but it radiates to the axilla, not the left sternal border.
Option B is incorrect: Tricuspid vegetation embolization would cause pulmonary embolism
symptoms but would not produce a new holosystolic murmur at the left sternal border.
,Option C is incorrect: ARDS from septic emboli would cause respiratory distress but does not
explain the new cardiac murmur.
Question 4.
A patient with hypertrophic cardiomyopathy (HCM) suddenly collapses in the hallway. The
nurse finds the patient unresponsive, pulseless, and apneic. Which intervention should the
nurse prioritize?
• A. Begin high-quality CPR with emphasis on rapid, deep compressions.
• B. Deliver a precordial thump and check for a response.
• C. Administer amiodarone 300 mg IV push immediately.
• D. Place the patient in the left lateral decubitus position.
Correct Answer: A
Rationale:
For a patient with HCM who suffers sudden cardiac arrest, immediate high-quality CPR is the
priority. HCM patients are at risk for ventricular fibrillation due to arrhythmogenic substrate;
CPR maintains cerebral and coronary perfusion until defibrillation can be performed.
Option B is incorrect: A precordial thump is only considered in witnessed, monitored arrests
when a defibrillator is not immediately available; it is not a substitute for CPR.
Option C is incorrect: Amiodarone is given for refractory ventricular fibrillation or pulseless VT
after defibrillation attempts, not as a first intervention in pulseless arrest.
Option D is incorrect: Left lateral decubitus position is used for pregnant patients to relieve
aortocaval compression and has no role in cardiac arrest management.
Question 5.
A patient with aortic dissection presents with tearing chest pain radiating to the back. Blood
pressure is 190/110 mmHg in the right arm and 140/88 mmHg in the left arm. Which
medication should the nurse prepare to administer first?
• A. IV nitroglycerin infusion.
• B. IV esmolol bolus followed by infusion.
• C. IV hydralazine push.
• D. Sublingual nifedipine.
Correct Answer: B
, Rationale:
Aortic dissection requires immediate reduction of shear stress on the aortic wall by lowering
heart rate and blood pressure. Esmolol, a short-acting beta-blocker, is the first-line agent
because it reduces both heart rate and contractility (dP/dt), which decreases aortic wall stress.
Vasodilators alone can increase shear stress by causing reflex tachycardia.
Option A is incorrect: Nitroglycerin primarily causes venodilation and can cause reflex
tachycardia, increasing aortic wall shear stress without beta-blockade.
Option C is incorrect: Hydralazine causes direct arterial vasodilation with significant reflex
tachycardia, which is dangerous in aortic dissection as it increases dP/dt and worsens dissection
propagation.
Option D is incorrect: Sublingual nifedipine causes rapid unpredictable blood pressure drops
and reflex tachycardia; it is contraindicated in aortic dissection.
Question 6.
A patient with a permanent pacemaker reports dizziness and syncope. Telemetry shows
intermittent failure to capture. The nurse checks the pacemaker threshold and notes it is 4.5
mA with the output set at 5.0 mA. Which action is most appropriate?
• A. Increase the pacemaker output to 7.0 mA.
• B. Decrease the sensitivity to make the pacemaker less sensitive.
• C. Replace the pacemaker battery immediately.
• D. Administer atropine 0.5 mg IV push.
Correct Answer: A
Rationale:
The pacing threshold is 4.5 mA with an output of 5.0 mA, leaving only a 0.5 mA safety margin.
The standard safety margin is at least twice the threshold or a minimum of 2.0 mA above
threshold. Increasing the output to 7.0 mA restores an adequate safety margin and should
resolve the failure to capture.
Option B is incorrect: Adjusting sensitivity addresses failure to sense (undersensing or
oversensing), not failure to capture. The problem described is failure to capture, which is an
output issue.
Option C is incorrect: Battery replacement is indicated by battery depletion indicators (elective
replacement indicator), not by elevated pacing thresholds, which indicate lead issues or tissue
changes at the electrode interface.
