NUR265 Exam 3
Advanced Concepts of Medical-Surgical Nursing
Complete Exam Review Guide with Questions and Verified Answers
Latest Update
Latest Update
Total Questions: 90
Cognitive Distribution: 25% Recall | 50% Application | 25% Analysis
Question Style: 80% Scenario-Based (NGN) | 20% Direct Recall
Content Coverage: 8 Sections - Cardiovascular, Respiratory, Neurological,
Renal/Endocrine, GI/Hepatic, Shock/Sepsis, Pharmacology, Clinical Judgment
Format: Multiple Choice (A-D) with Verified Answers and Rationales
This comprehensive exam review guide is designed to prepare nursing students for NUR265 Exam 3: Advanced
Concepts of Medical-Surgical Nursing. The 90 questions in this guide span complex cardiovascular, respiratory,
neurological, renal, endocrine, gastrointestinal, hepatic, shock, sepsis, and critical care pharmacology concepts
aligned with the 2026/2027 curriculum standards. Each question is accompanied by a verified answer and a detailed
rationale that integrates pathophysiology, evidence-based guidelines, pharmacological mechanisms, and expert
clinical judgment. The cognitive level distribution (25% recall, 50% application, 25% analysis) and the integration of
Next-Generation NCLEX (NGN) clinical judgment scenarios ensure that students develop the reasoning skills
required for advanced medical-surgical nursing practice.
Section 1: Complex Cardiovascular Disorders | Q1 - Q16
Q1: A 68-year-old male with a history of ischemic cardiomyopathy and an ejection fraction of 28% is
admitted with acute decompensated heart failure (ADHF). He has bibasilar crackles, JVD to the angle of the
jaw, and an SpO2 of 88% on room air. His BP is 168/96, HR 112 and irregular, and he is orthopneic. Which
sequence of pharmacologic interventions best reflects the 2026 ACC/AHA guideline-concordant management
of this patient?
A. Initiate IV labetalol for rate control, then start IV furosemide, and begin IV enalaprilat.
B. Administer IV morphine for dyspnea, give IV furosemide, and begin IV dopamine for low output.
C. Administer high-flow oxygen, give IV furosemide, start IV nitroglycerin infusion, and consider IV
nesiritide. [CORRECT]
D. Give IV furosemide, start IV nitroprusside, and add IV digoxin for inotropic support.
NUR265 Exam 3 - Advanced Concepts of Medical-Surgical Nursing (2026/2027) Page 1
, Correct Answer: C
Rationale:
In acute decompensated heart failure with pulmonary congestion and hypertension (BP 168/96), the 2026
ACC/AHA guideline-concordant approach is to administer oxygen for hypoxia, IV loop diuretics
(furosemide) for volume overload, and a vasodilator such as IV nitroglycerin to reduce preload and
afterload given the elevated blood pressure. Nesiritide may be considered for dyspnea relief in selected
patients. Option A is incorrect because beta-blockers are contraindicated in acute decompensated HF and
ACE inhibitors are not initiated IV in the acute setting. Option B is incorrect because morphine increases
ICU admission and mortality risk per recent data, and dopamine is not first-line for low output. Option D
is incorrect because nitroprusside carries cyanide toxicity risk and digoxin is not an acute inotrope of
choice.
Q2: A patient is admitted with a hypertensive emergency and a suspected Stanford Type B aortic dissection.
Which assessment finding most strongly supports the diagnosis of aortic dissection rather than acute
myocardial infarction?
A. Substernal chest pressure that radiates to the left arm and jaw.
B. A tearing or ripping sensation in the back or chest with blood pressure differential >20 mmHg between
arms. [CORRECT]
C. Pleuritic chest pain that worsens with deep inspiration and a friction rub on auscultation.
D. Sudden onset of dyspnea, pleuritic chest pain, and hemoptysis following a long flight.
Correct Answer: B
Rationale:
The classic presentation of aortic dissection is sudden, tearing or ripping chest or back pain, often with a
blood pressure differential of greater than 20 mmHg between the upper extremities due to involvement of
the subclavian artery. Stanford Type B dissections involve the descending aorta distal to the left subclavian
and are typically managed medically with blood pressure control. Option A describes acute MI. Option C
describes pericarditis. Option D describes pulmonary embolism. Diagnosis is confirmed with CT
angiography, transesophageal echocardiography, or MRI. Immediate management focuses on controlling
heart rate and blood pressure with IV beta-blockers followed by vasodilators to reduce shear stress on the
aortic wall.
Q3: A 54-year-old female is brought to the ED with dyspnea, hypotension (BP 84/52), JVD, and muffled heart
sounds. The nurse observes a decrease in systolic BP of 15 mmHg during inspiration. Which emergency
intervention is the priority?
A. Administer IV fluids rapidly to increase preload while awaiting emergent pericardiocentesis. [CORRECT]
B. Begin IV metoprolol to reduce myocardial oxygen demand and tachycardia.
C. Administer IV furosemide to reduce intravascular volume and right-sided filling pressure.
D. Initiate IV norepinephrine to maintain systemic vascular resistance.
Correct Answer: A
Rationale:
NUR265 Exam 3 - Advanced Concepts of Medical-Surgical Nursing (2026/2027) Page 2
, The patient is presenting with Beck's triad (hypotension, JVD, muffled heart sounds) and pulsus paradoxus
(systolic BP drop >10 mmHg on inspiration), consistent with cardiac tamponade - a life-threatening
condition caused by fluid accumulation in the pericardial space compressing the heart. The priority
intervention is to administer IV fluids rapidly to increase preload and maintain cardiac output while
preparing for emergent pericardiocentesis, the definitive treatment. Option B is incorrect because
beta-blockers would worsen the compensatory tachycardia maintaining cardiac output. Option C is
incorrect because diuretics would further reduce preload and worsen cardiac compression. Option D may
be used adjunctively but does not address the underlying pathology of pericardial fluid compression.
Q4: A patient with hypertrophic cardiomyopathy (HCM) is being evaluated for medical management. Which
pharmacologic regimen is most appropriate to reduce the dynamic left ventricular outflow tract (LVOT)
obstruction and improve symptoms?
A. IV furosemide to decrease preload and reduce ventricular filling.
B. IV nitroglycerin to decrease afterload and improve coronary perfusion.
C. Oral metoprolol to reduce heart rate and myocardial contractility. [CORRECT]
D. Oral digoxin to increase contractility and improve cardiac output.
Correct Answer: C
Rationale:
In hypertrophic cardiomyopathy, the dynamic LVOT obstruction is worsened by increased contractility,
decreased preload, and decreased afterload. Beta-blockers (metoprolol) are first-line therapy because they
reduce heart rate (allowing increased ventricular filling time) and decrease myocardial contractility, both
of which reduce the LVOT gradient. Option A is incorrect because decreasing preload worsens the
obstruction by reducing ventricular volume. Option B is incorrect because decreasing afterload worsens
the gradient by allowing more forward flow past the obstruction. Option D is incorrect because increasing
contractility worsens the dynamic obstruction. Non-dihydropyridine calcium channel blockers (verapamil)
are an alternative when beta-blockers are contraindicated.
Q5: A 72-year-old male with severe aortic stenosis presents with exertional angina, syncope, and heart failure
symptoms. On auscultation, the nurse notes a crescendo-decrescendo systolic murmur best heard at the
second right intercostal space radiating to the carotids. Which hemodynamic finding would most likely be
present on cardiac catheterization?
A. Increased left ventricular end-diastolic pressure with a gradient <10 mmHg across the aortic valve.
B. A systolic pressure gradient >40 mmHg across the aortic valve with elevated left ventricular pressures.
[CORRECT]
C. A large v-wave in the pulmonary capillary wedge pressure tracing indicating severe mitral regurgitation.
D. Equalization of diastolic pressures in all four chambers suggesting constrictive pericarditis.
Correct Answer: B
Rationale:
Severe aortic stenosis is defined by a valve area less than 1.0 cm2 or a mean systolic gradient greater than
40 mmHg. The classic triad of symptoms includes angina, syncope, and heart failure, which indicate
advanced disease requiring valve replacement. The crescendo-decrescendo systolic murmur at the second
right intercostal space radiating to the carotids is pathognomonic. The increased afterload from the stenotic
valve leads to left ventricular hypertrophy and elevated LV pressures. Option A describes mild aortic
stenosis. Option C describes severe mitral regurgitation. Option D describes constrictive pericarditis.
Definitive treatment is aortic valve replacement (SAVR or TAVR depending on surgical risk).
NUR265 Exam 3 - Advanced Concepts of Medical-Surgical Nursing (2026/2027) Page 3
, Q6: A patient with dilated cardiomyopathy and an ejection fraction of 22% has an implantable
cardioverter-defibrillator (ICD) placed for primary prevention of sudden cardiac death. The patient receives
an appropriate ICD shock for ventricular tachycardia. Which nursing intervention is most appropriate
immediately following the shock?
A. Deactivate the ICD to prevent further shocks and call electrophysiology.
B. Assess the patient's vital signs, level of consciousness, and oxygenation, and document the event.
[CORRECT]
C. Administer IV amiodarone 150 mg bolus to prevent recurrent VT regardless of patient status.
D. Recommend the patient avoid driving for life due to the risk of recurrent arrhythmias.
Correct Answer: B
Rationale:
After an ICD shock, the nurse should immediately assess the patient's vital signs, level of consciousness,
and oxygenation status, and document the event including the number of shocks and patient symptoms.
The ICD is functioning appropriately and should not be deactivated. Option A is incorrect because the ICD
is providing life-saving therapy. Option C is incorrect because antiarrhythmic therapy is not automatically
indicated after a single appropriate shock; it is reserved for recurrent VT/VF or electrical storm (3 or more
episodes in 24 hours). Option D is incorrect because driving restrictions are typically 6 months after an
appropriate shock, not lifelong. The patient should be monitored for recurrent arrhythmias and the device
interrogated to confirm appropriate therapy.
Q7: A 45-year-old female with a history of rheumatic heart disease presents with progressive dyspnea, fatigue,
and a holosystolic murmur at the apex radiating to the axilla. Echocardiography confirms severe mitral
regurgitation with a flail leaflet. Which finding would be most concerning for progression to decompensated
heart failure requiring surgical intervention?
A. A pulmonary artery systolic pressure of 35 mmHg on echocardiography.
B. Left ventricular ejection fraction of 60% with LV end-systolic diameter of 38 mm.
C. Left ventricular ejection fraction of 58% with LV end-systolic diameter of 42 mm and PASP of 55 mmHg.
[CORRECT]
D. A soft S3 gallop with stable weight and no exertional symptoms.
Correct Answer: C
Rationale:
In chronic severe mitral regurgitation, surgical intervention (mitral valve repair or replacement) is
indicated when symptoms develop or when there is evidence of left ventricular dysfunction. Specific
triggers include LV ejection fraction falling below 60% or LV end-systolic diameter increasing to 40 mm
or greater, or new-onset pulmonary hypertension (PASP >50 mmHg). Option C meets multiple criteria
with an EF still above 60% but LVESD >40 mm and significant pulmonary hypertension, indicating early
LV decompensation. Option A is not yet concerning. Option B shows preserved LV function. Option D
shows compensated disease. Early surgical intervention before irreversible LV dysfunction occurs is
critical for optimal outcomes.
Q8: A patient with end-stage heart failure (NYHA Class IV, EF 18%) has an LVAD (Left Ventricular Assist
Device) placed as destination therapy. Which finding would indicate a potential pump thrombosis requiring
immediate intervention?
A. Hemoglobin of 9.2 g/dL with dark tea-colored urine and a sudden increase in pump power. [CORRECT]
B. Mild epistaxis controlled with pressure and an INR of 2.5.
NUR265 Exam 3 - Advanced Concepts of Medical-Surgical Nursing (2026/2027) Page 4
Advanced Concepts of Medical-Surgical Nursing
Complete Exam Review Guide with Questions and Verified Answers
Latest Update
Latest Update
Total Questions: 90
Cognitive Distribution: 25% Recall | 50% Application | 25% Analysis
Question Style: 80% Scenario-Based (NGN) | 20% Direct Recall
Content Coverage: 8 Sections - Cardiovascular, Respiratory, Neurological,
Renal/Endocrine, GI/Hepatic, Shock/Sepsis, Pharmacology, Clinical Judgment
Format: Multiple Choice (A-D) with Verified Answers and Rationales
This comprehensive exam review guide is designed to prepare nursing students for NUR265 Exam 3: Advanced
Concepts of Medical-Surgical Nursing. The 90 questions in this guide span complex cardiovascular, respiratory,
neurological, renal, endocrine, gastrointestinal, hepatic, shock, sepsis, and critical care pharmacology concepts
aligned with the 2026/2027 curriculum standards. Each question is accompanied by a verified answer and a detailed
rationale that integrates pathophysiology, evidence-based guidelines, pharmacological mechanisms, and expert
clinical judgment. The cognitive level distribution (25% recall, 50% application, 25% analysis) and the integration of
Next-Generation NCLEX (NGN) clinical judgment scenarios ensure that students develop the reasoning skills
required for advanced medical-surgical nursing practice.
Section 1: Complex Cardiovascular Disorders | Q1 - Q16
Q1: A 68-year-old male with a history of ischemic cardiomyopathy and an ejection fraction of 28% is
admitted with acute decompensated heart failure (ADHF). He has bibasilar crackles, JVD to the angle of the
jaw, and an SpO2 of 88% on room air. His BP is 168/96, HR 112 and irregular, and he is orthopneic. Which
sequence of pharmacologic interventions best reflects the 2026 ACC/AHA guideline-concordant management
of this patient?
A. Initiate IV labetalol for rate control, then start IV furosemide, and begin IV enalaprilat.
B. Administer IV morphine for dyspnea, give IV furosemide, and begin IV dopamine for low output.
C. Administer high-flow oxygen, give IV furosemide, start IV nitroglycerin infusion, and consider IV
nesiritide. [CORRECT]
D. Give IV furosemide, start IV nitroprusside, and add IV digoxin for inotropic support.
NUR265 Exam 3 - Advanced Concepts of Medical-Surgical Nursing (2026/2027) Page 1
, Correct Answer: C
Rationale:
In acute decompensated heart failure with pulmonary congestion and hypertension (BP 168/96), the 2026
ACC/AHA guideline-concordant approach is to administer oxygen for hypoxia, IV loop diuretics
(furosemide) for volume overload, and a vasodilator such as IV nitroglycerin to reduce preload and
afterload given the elevated blood pressure. Nesiritide may be considered for dyspnea relief in selected
patients. Option A is incorrect because beta-blockers are contraindicated in acute decompensated HF and
ACE inhibitors are not initiated IV in the acute setting. Option B is incorrect because morphine increases
ICU admission and mortality risk per recent data, and dopamine is not first-line for low output. Option D
is incorrect because nitroprusside carries cyanide toxicity risk and digoxin is not an acute inotrope of
choice.
Q2: A patient is admitted with a hypertensive emergency and a suspected Stanford Type B aortic dissection.
Which assessment finding most strongly supports the diagnosis of aortic dissection rather than acute
myocardial infarction?
A. Substernal chest pressure that radiates to the left arm and jaw.
B. A tearing or ripping sensation in the back or chest with blood pressure differential >20 mmHg between
arms. [CORRECT]
C. Pleuritic chest pain that worsens with deep inspiration and a friction rub on auscultation.
D. Sudden onset of dyspnea, pleuritic chest pain, and hemoptysis following a long flight.
Correct Answer: B
Rationale:
The classic presentation of aortic dissection is sudden, tearing or ripping chest or back pain, often with a
blood pressure differential of greater than 20 mmHg between the upper extremities due to involvement of
the subclavian artery. Stanford Type B dissections involve the descending aorta distal to the left subclavian
and are typically managed medically with blood pressure control. Option A describes acute MI. Option C
describes pericarditis. Option D describes pulmonary embolism. Diagnosis is confirmed with CT
angiography, transesophageal echocardiography, or MRI. Immediate management focuses on controlling
heart rate and blood pressure with IV beta-blockers followed by vasodilators to reduce shear stress on the
aortic wall.
Q3: A 54-year-old female is brought to the ED with dyspnea, hypotension (BP 84/52), JVD, and muffled heart
sounds. The nurse observes a decrease in systolic BP of 15 mmHg during inspiration. Which emergency
intervention is the priority?
A. Administer IV fluids rapidly to increase preload while awaiting emergent pericardiocentesis. [CORRECT]
B. Begin IV metoprolol to reduce myocardial oxygen demand and tachycardia.
C. Administer IV furosemide to reduce intravascular volume and right-sided filling pressure.
D. Initiate IV norepinephrine to maintain systemic vascular resistance.
Correct Answer: A
Rationale:
NUR265 Exam 3 - Advanced Concepts of Medical-Surgical Nursing (2026/2027) Page 2
, The patient is presenting with Beck's triad (hypotension, JVD, muffled heart sounds) and pulsus paradoxus
(systolic BP drop >10 mmHg on inspiration), consistent with cardiac tamponade - a life-threatening
condition caused by fluid accumulation in the pericardial space compressing the heart. The priority
intervention is to administer IV fluids rapidly to increase preload and maintain cardiac output while
preparing for emergent pericardiocentesis, the definitive treatment. Option B is incorrect because
beta-blockers would worsen the compensatory tachycardia maintaining cardiac output. Option C is
incorrect because diuretics would further reduce preload and worsen cardiac compression. Option D may
be used adjunctively but does not address the underlying pathology of pericardial fluid compression.
Q4: A patient with hypertrophic cardiomyopathy (HCM) is being evaluated for medical management. Which
pharmacologic regimen is most appropriate to reduce the dynamic left ventricular outflow tract (LVOT)
obstruction and improve symptoms?
A. IV furosemide to decrease preload and reduce ventricular filling.
B. IV nitroglycerin to decrease afterload and improve coronary perfusion.
C. Oral metoprolol to reduce heart rate and myocardial contractility. [CORRECT]
D. Oral digoxin to increase contractility and improve cardiac output.
Correct Answer: C
Rationale:
In hypertrophic cardiomyopathy, the dynamic LVOT obstruction is worsened by increased contractility,
decreased preload, and decreased afterload. Beta-blockers (metoprolol) are first-line therapy because they
reduce heart rate (allowing increased ventricular filling time) and decrease myocardial contractility, both
of which reduce the LVOT gradient. Option A is incorrect because decreasing preload worsens the
obstruction by reducing ventricular volume. Option B is incorrect because decreasing afterload worsens
the gradient by allowing more forward flow past the obstruction. Option D is incorrect because increasing
contractility worsens the dynamic obstruction. Non-dihydropyridine calcium channel blockers (verapamil)
are an alternative when beta-blockers are contraindicated.
Q5: A 72-year-old male with severe aortic stenosis presents with exertional angina, syncope, and heart failure
symptoms. On auscultation, the nurse notes a crescendo-decrescendo systolic murmur best heard at the
second right intercostal space radiating to the carotids. Which hemodynamic finding would most likely be
present on cardiac catheterization?
A. Increased left ventricular end-diastolic pressure with a gradient <10 mmHg across the aortic valve.
B. A systolic pressure gradient >40 mmHg across the aortic valve with elevated left ventricular pressures.
[CORRECT]
C. A large v-wave in the pulmonary capillary wedge pressure tracing indicating severe mitral regurgitation.
D. Equalization of diastolic pressures in all four chambers suggesting constrictive pericarditis.
Correct Answer: B
Rationale:
Severe aortic stenosis is defined by a valve area less than 1.0 cm2 or a mean systolic gradient greater than
40 mmHg. The classic triad of symptoms includes angina, syncope, and heart failure, which indicate
advanced disease requiring valve replacement. The crescendo-decrescendo systolic murmur at the second
right intercostal space radiating to the carotids is pathognomonic. The increased afterload from the stenotic
valve leads to left ventricular hypertrophy and elevated LV pressures. Option A describes mild aortic
stenosis. Option C describes severe mitral regurgitation. Option D describes constrictive pericarditis.
Definitive treatment is aortic valve replacement (SAVR or TAVR depending on surgical risk).
NUR265 Exam 3 - Advanced Concepts of Medical-Surgical Nursing (2026/2027) Page 3
, Q6: A patient with dilated cardiomyopathy and an ejection fraction of 22% has an implantable
cardioverter-defibrillator (ICD) placed for primary prevention of sudden cardiac death. The patient receives
an appropriate ICD shock for ventricular tachycardia. Which nursing intervention is most appropriate
immediately following the shock?
A. Deactivate the ICD to prevent further shocks and call electrophysiology.
B. Assess the patient's vital signs, level of consciousness, and oxygenation, and document the event.
[CORRECT]
C. Administer IV amiodarone 150 mg bolus to prevent recurrent VT regardless of patient status.
D. Recommend the patient avoid driving for life due to the risk of recurrent arrhythmias.
Correct Answer: B
Rationale:
After an ICD shock, the nurse should immediately assess the patient's vital signs, level of consciousness,
and oxygenation status, and document the event including the number of shocks and patient symptoms.
The ICD is functioning appropriately and should not be deactivated. Option A is incorrect because the ICD
is providing life-saving therapy. Option C is incorrect because antiarrhythmic therapy is not automatically
indicated after a single appropriate shock; it is reserved for recurrent VT/VF or electrical storm (3 or more
episodes in 24 hours). Option D is incorrect because driving restrictions are typically 6 months after an
appropriate shock, not lifelong. The patient should be monitored for recurrent arrhythmias and the device
interrogated to confirm appropriate therapy.
Q7: A 45-year-old female with a history of rheumatic heart disease presents with progressive dyspnea, fatigue,
and a holosystolic murmur at the apex radiating to the axilla. Echocardiography confirms severe mitral
regurgitation with a flail leaflet. Which finding would be most concerning for progression to decompensated
heart failure requiring surgical intervention?
A. A pulmonary artery systolic pressure of 35 mmHg on echocardiography.
B. Left ventricular ejection fraction of 60% with LV end-systolic diameter of 38 mm.
C. Left ventricular ejection fraction of 58% with LV end-systolic diameter of 42 mm and PASP of 55 mmHg.
[CORRECT]
D. A soft S3 gallop with stable weight and no exertional symptoms.
Correct Answer: C
Rationale:
In chronic severe mitral regurgitation, surgical intervention (mitral valve repair or replacement) is
indicated when symptoms develop or when there is evidence of left ventricular dysfunction. Specific
triggers include LV ejection fraction falling below 60% or LV end-systolic diameter increasing to 40 mm
or greater, or new-onset pulmonary hypertension (PASP >50 mmHg). Option C meets multiple criteria
with an EF still above 60% but LVESD >40 mm and significant pulmonary hypertension, indicating early
LV decompensation. Option A is not yet concerning. Option B shows preserved LV function. Option D
shows compensated disease. Early surgical intervention before irreversible LV dysfunction occurs is
critical for optimal outcomes.
Q8: A patient with end-stage heart failure (NYHA Class IV, EF 18%) has an LVAD (Left Ventricular Assist
Device) placed as destination therapy. Which finding would indicate a potential pump thrombosis requiring
immediate intervention?
A. Hemoglobin of 9.2 g/dL with dark tea-colored urine and a sudden increase in pump power. [CORRECT]
B. Mild epistaxis controlled with pressure and an INR of 2.5.
NUR265 Exam 3 - Advanced Concepts of Medical-Surgical Nursing (2026/2027) Page 4
