NUR265 Exam 3 — Advanced Medical-Surgical Nursing (2026/2027 Update) Galen College of Nursing
NUR265 Exam 3: Advanced Medical-Surgical
Nursing Review
(2026/2027 Update) — Advanced Med-Surg Review | Questions and Verified Answers | 100%
Correct
Galen College of Nursing | 85 Questions | Cognitive Distribution: 25% Recall, 50% Application, 25% Analysis
Exam Instructions: This examination consists of 85 multiple-choice and NGN-enhanced questions divided into 8 sections. Each
question has ONE best answer unless specified as extended multiple response. Select the single best answer for each question.
Rationales are provided with pathophysiologic, pharmacologic, and evidence-based reasoning per current critical care guidelines
(AHA/ACC 2022, Surviving Sepsis Campaign 2021, KDIGO 2023, Brain Trauma Foundation, ARDSNet, and ADA Standards of
Care).
Section 1: Complex Cardiovascular Disorders
Heart Failure, Cardiac Tamponade, Aortic Dissection, Valvular Disorders, and Cardiomyopathies. Questions focus on
hemodynamic monitoring, pharmacological interventions, and emergency management of life-threatening cardiac
conditions.
Q1: A 68-year-old male with a history of ischemic cardiomyopathy (EF 28%) is admitted with acute
decompensated heart failure. He has crackles bilaterally, JVD, and an S3 gallop. BNP is 1,820 pg/mL.
Which pharmacological intervention should the nurse anticipate as the FIRST priority to rapidly reduce
preload and improve dyspnea?
A. Administer oral furosemide 40 mg to initiate diuresis
B. Start a dobutamine infusion at 2.5 mcg/kg/min for inotropic support
C. Administer IV furosemide 40 mg bolus followed by continuous infusion [CORRECT]
D. Initiate IV nitroglycerin infusion titrated to relieve pulmonary congestion
Correct Answer: C
Rationale: In acute decompensated heart failure (ADHF) with volume overload, IV loop diuretics are the cornerstone
of initial therapy. IV administration bypasses impaired gut perfusion and lymphatic congestion seen in ADHF, achieving
therapeutic levels within minutes. The DOSE trial established that high-dose IV furosemide (either bolus or continuous
infusion) is preferred over oral therapy for symptomatic relief. While IV nitroglycerin can reduce preload, diuresis
addresses the underlying volume overload. Dobutamine is reserved for low-output states with hypoperfusion, not
isolated congestion.
Page 1 | NUR265 Exam 3 — 100% Verified Answers
,NUR265 Exam 3 — Advanced Medical-Surgical Nursing (2026/2027 Update) Galen College of Nursing
Q2: A patient with chronic systolic heart failure (HFrEF) is being discharged on guideline-directed
medical therapy (GDMT). The patient's current medications include lisinopril 20 mg daily and furosemide
40 mg daily. Vital signs: BP 110/68, HR 78, K+ 4.2 mEq/L. Which medication addition is MOST critical to
add per the 2022 AHA/ACC/HFSA guidelines to reduce mortality in HFrEF?
A. Add hydralazine/isosorbide dinitrate due to African American heritage
B. Add sacubitril/valsartan (ARNI) to replace lisinopril
C. Add carvedilol titrated to target dose, then add spironolactone and SGLT2 inhibitor
[CORRECT]
D. Add digoxin for symptom control and reduced hospitalizations
Correct Answer: C
Rationale: The 2022 AHA/ACC/HFSA guidelines establish the "four pillars" of GDMT for HFrEF: beta-blocker
(carvedilol, metoprolol succinate, or bisoprolol), ARNI (preferred over ACEi/ARB), MRA (spironolactone), and
SGLT2 inhibitor (dapagliflozin or empagliflozin). Beta-blockers must be initiated when the patient is euvolemic and
titrated gradually. ARNI is preferred but requires 36-hour washout from ACE inhibitor to prevent angioedema. Digoxin
reduces hospitalizations but has NO mortality benefit. Hydralazine/isosorbide is reserved for African American patients
who remain symptomatic despite optimal GDMT.
Q3: A 52-year-old male post-CABG day 4 develops sudden hypotension (BP 84/52), JVD to the angle of the
jaw, and muffled heart sounds on auscultation. His heart rate is 118 and pulsus paradoxus of 18 mmHg is
noted. Which classic triad is this presentation demonstrating, and what is the priority intervention?
A. Beck's triad — immediate pericardiocentesis [CORRECT]
B. Cushing's triad — IV mannitol and hyperventilation
C. Beck's triad — rapid IV fluid bolus followed by pericardiocentesis
D. Virchow's triad — anticoagulation therapy
Correct Answer: A
Rationale: Beck's triad (hypotension, distended neck veins, muffled heart sounds) with pulsus paradoxus >10 mmHg is
pathognomonic for cardiac tamponade — a life-threatening compression of the heart by pericardial fluid. The
immediate intervention is pericardiocentesis to remove the compressive fluid. While IV fluids may temporarily augment
preload to compensate for impaired ventricular filling, they are NOT definitive treatment and should not delay
pericardiocentesis. Cushing's triad (HTN, bradycardia, irregular respirations) indicates increased ICP. Virchow's triad
describes venous thromboembolism risk factors. Delaying pericardiocentesis for fluid resuscitation risks progression to
pulseless electrical activity (PEA) arrest.
Page 2 | NUR265 Exam 3 — 100% Verified Answers
,NUR265 Exam 3 — Advanced Medical-Surgical Nursing (2026/2027 Update) Galen College of Nursing
Q4: A patient with end-stage renal disease on hemodialysis presents with cardiac tamponade. The nurse
prepares for emergent pericardiocentesis. The physician orders fluid resuscitation en route to the
procedure suite. Which rationale BEST supports administering IV fluids in tamponade?
A. Fluids increase myocardial contractility to overcome compression
B. Fluids increase preload to maximize stroke volume despite impaired ventricular filling
[CORRECT]
C. Fluids dilute the pericardial fluid to reduce viscosity
D. Fluids prevent hypotension from anesthetic agents only
Correct Answer: B
Rationale: In cardiac tamponade, intrapericardial pressure exceeds ventricular filling pressure, severely restricting
preload. The compensatory mechanism is tachycardia and increased filling pressure to maintain cardiac output. IV fluids
transiently augment venous return, increasing right atrial pressure above intrapericardial pressure to maintain ventricular
filling gradient. Fluids do NOT improve contractility or alter pericardial fluid viscosity. This is a temporizing bridge to
definitive pericardiocentesis — the only intervention that addresses the underlying pathology. Excessive fluid can
precipitate right ventricular failure in chronic tamponade, so judicious boluses (250 mL aliquots) are recommended.
Q5: A 58-year-old male presents with sudden, tearing chest pain radiating to his back between the
scapulae. BP is 168/98 in the right arm and 142/88 in the left arm (differential >20 mmHg). CT
angiography reveals an aortic dissection involving the ascending aorta with the intimal tear at the
sinotubular junction. According to the Stanford classification, which type is this and what is the priority
management?
A. Stanford Type B — medical management with IV beta-blockers and analgesia
B. Stanford Type A — emergent surgical repair [CORRECT]
C. Stanford Type B — endovascular stent graft placement
D. Stanford Type A — aggressive BP control with IV nitroprusside only
Correct Answer: B
Rationale: The Stanford classification divides aortic dissections into Type A (involving the ascending aorta, regardless
of tear origin) and Type B (limited to the descending aorta distal to the left subclavian artery). Type A dissections are
surgical emergencies due to risk of rupture into the pericardium causing tamponade, acute aortic regurgitation, coronary
artery occlusion, or stroke — mortality increases 1-2% per hour without repair. Type B dissections are managed
medically with IV beta-blockers to reduce shear stress (target HR <60, SBP 100-120). Endovascular repair is reserved
for complicated Type B dissections with malperfusion, rupture, or expansion.
Page 3 | NUR265 Exam 3 — 100% Verified Answers
, NUR265 Exam 3 — Advanced Medical-Surgical Nursing (2026/2027 Update) Galen College of Nursing
Q6: A 64-year-old female with a Stanford Type B aortic dissection is admitted to the ICU. BP is 178/105,
HR 112. The nurse anticipates initiation of IV labetalol. Which BEST explains the rationale for
beta-blockade BEFORE initiating vasodilators like nicardipine or nitroprusside in acute aortic dissection?
A. Beta-blockers reduce the dP/dt (rate of pressure rise) to decrease shear stress on the intimal tear
[CORRECT]
B. Vasodilators cause reflex tachycardia that worsens dissection propagation
C. Beta-blockers prevent renal artery involvement in Type B dissections
D. Vasodilators are contraindicated in hypertensive patients over 60
Correct Answer: A
Rationale: In acute aortic dissection, the priority is reducing the rate of pressure rise (dP/dt) — the shear force that
propagates the intimal tear. IV beta-blockers (esmolol or labetalol) are first-line to achieve HR <60 and SBP 100-120.
Initiating pure vasodilators (nitroprusside, nicardipine) WITHOUT prior beta-blockade causes reflex tachycardia, which
increases dP/dt and accelerates dissection propagation — a critical error. If vasodilators are needed after adequate
beta-blockade, they are added as second-line agents. Esmolol is preferred in unstable patients due to its short half-term
(9 minutes) allowing rapid titration.
Q7: A 72-year-old male with severe aortic stenosis (AVA 0.6 cm², mean gradient 50 mmHg) presents with
exertional angina, syncope, and heart failure. He reports symptoms have worsened over 3 months. Which
intervention offers the ONLY definitive treatment with proven mortality benefit?
A. Balloon aortic valvuloplasty to relieve stenosis
B. Medical management with beta-blockers and diuretics
C. Transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR)
[CORRECT]
D. Dual antiplatelet therapy with aspirin and clopidogrel
Correct Answer: C
Rationale: Severe symptomatic aortic stenosis with the classic triad (angina, syncope, heart failure) carries a 50%
2-year mortality without valve replacement. TAVR (for patients ≥65 or high surgical risk) and SAVR (younger,
lower-risk patients) are the only definitive treatments with proven mortality benefit. Balloon valvuloplasty provides only
transient relief (weeks to months) and is reserved as a bridge in critically ill patients. Medical therapy does not alter
disease progression. Once symptoms develop, mean survival is 2-3 years without intervention, with sudden cardiac death
accounting for 20% of mortality.
Page 4 | NUR265 Exam 3 — 100% Verified Answers
NUR265 Exam 3: Advanced Medical-Surgical
Nursing Review
(2026/2027 Update) — Advanced Med-Surg Review | Questions and Verified Answers | 100%
Correct
Galen College of Nursing | 85 Questions | Cognitive Distribution: 25% Recall, 50% Application, 25% Analysis
Exam Instructions: This examination consists of 85 multiple-choice and NGN-enhanced questions divided into 8 sections. Each
question has ONE best answer unless specified as extended multiple response. Select the single best answer for each question.
Rationales are provided with pathophysiologic, pharmacologic, and evidence-based reasoning per current critical care guidelines
(AHA/ACC 2022, Surviving Sepsis Campaign 2021, KDIGO 2023, Brain Trauma Foundation, ARDSNet, and ADA Standards of
Care).
Section 1: Complex Cardiovascular Disorders
Heart Failure, Cardiac Tamponade, Aortic Dissection, Valvular Disorders, and Cardiomyopathies. Questions focus on
hemodynamic monitoring, pharmacological interventions, and emergency management of life-threatening cardiac
conditions.
Q1: A 68-year-old male with a history of ischemic cardiomyopathy (EF 28%) is admitted with acute
decompensated heart failure. He has crackles bilaterally, JVD, and an S3 gallop. BNP is 1,820 pg/mL.
Which pharmacological intervention should the nurse anticipate as the FIRST priority to rapidly reduce
preload and improve dyspnea?
A. Administer oral furosemide 40 mg to initiate diuresis
B. Start a dobutamine infusion at 2.5 mcg/kg/min for inotropic support
C. Administer IV furosemide 40 mg bolus followed by continuous infusion [CORRECT]
D. Initiate IV nitroglycerin infusion titrated to relieve pulmonary congestion
Correct Answer: C
Rationale: In acute decompensated heart failure (ADHF) with volume overload, IV loop diuretics are the cornerstone
of initial therapy. IV administration bypasses impaired gut perfusion and lymphatic congestion seen in ADHF, achieving
therapeutic levels within minutes. The DOSE trial established that high-dose IV furosemide (either bolus or continuous
infusion) is preferred over oral therapy for symptomatic relief. While IV nitroglycerin can reduce preload, diuresis
addresses the underlying volume overload. Dobutamine is reserved for low-output states with hypoperfusion, not
isolated congestion.
Page 1 | NUR265 Exam 3 — 100% Verified Answers
,NUR265 Exam 3 — Advanced Medical-Surgical Nursing (2026/2027 Update) Galen College of Nursing
Q2: A patient with chronic systolic heart failure (HFrEF) is being discharged on guideline-directed
medical therapy (GDMT). The patient's current medications include lisinopril 20 mg daily and furosemide
40 mg daily. Vital signs: BP 110/68, HR 78, K+ 4.2 mEq/L. Which medication addition is MOST critical to
add per the 2022 AHA/ACC/HFSA guidelines to reduce mortality in HFrEF?
A. Add hydralazine/isosorbide dinitrate due to African American heritage
B. Add sacubitril/valsartan (ARNI) to replace lisinopril
C. Add carvedilol titrated to target dose, then add spironolactone and SGLT2 inhibitor
[CORRECT]
D. Add digoxin for symptom control and reduced hospitalizations
Correct Answer: C
Rationale: The 2022 AHA/ACC/HFSA guidelines establish the "four pillars" of GDMT for HFrEF: beta-blocker
(carvedilol, metoprolol succinate, or bisoprolol), ARNI (preferred over ACEi/ARB), MRA (spironolactone), and
SGLT2 inhibitor (dapagliflozin or empagliflozin). Beta-blockers must be initiated when the patient is euvolemic and
titrated gradually. ARNI is preferred but requires 36-hour washout from ACE inhibitor to prevent angioedema. Digoxin
reduces hospitalizations but has NO mortality benefit. Hydralazine/isosorbide is reserved for African American patients
who remain symptomatic despite optimal GDMT.
Q3: A 52-year-old male post-CABG day 4 develops sudden hypotension (BP 84/52), JVD to the angle of the
jaw, and muffled heart sounds on auscultation. His heart rate is 118 and pulsus paradoxus of 18 mmHg is
noted. Which classic triad is this presentation demonstrating, and what is the priority intervention?
A. Beck's triad — immediate pericardiocentesis [CORRECT]
B. Cushing's triad — IV mannitol and hyperventilation
C. Beck's triad — rapid IV fluid bolus followed by pericardiocentesis
D. Virchow's triad — anticoagulation therapy
Correct Answer: A
Rationale: Beck's triad (hypotension, distended neck veins, muffled heart sounds) with pulsus paradoxus >10 mmHg is
pathognomonic for cardiac tamponade — a life-threatening compression of the heart by pericardial fluid. The
immediate intervention is pericardiocentesis to remove the compressive fluid. While IV fluids may temporarily augment
preload to compensate for impaired ventricular filling, they are NOT definitive treatment and should not delay
pericardiocentesis. Cushing's triad (HTN, bradycardia, irregular respirations) indicates increased ICP. Virchow's triad
describes venous thromboembolism risk factors. Delaying pericardiocentesis for fluid resuscitation risks progression to
pulseless electrical activity (PEA) arrest.
Page 2 | NUR265 Exam 3 — 100% Verified Answers
,NUR265 Exam 3 — Advanced Medical-Surgical Nursing (2026/2027 Update) Galen College of Nursing
Q4: A patient with end-stage renal disease on hemodialysis presents with cardiac tamponade. The nurse
prepares for emergent pericardiocentesis. The physician orders fluid resuscitation en route to the
procedure suite. Which rationale BEST supports administering IV fluids in tamponade?
A. Fluids increase myocardial contractility to overcome compression
B. Fluids increase preload to maximize stroke volume despite impaired ventricular filling
[CORRECT]
C. Fluids dilute the pericardial fluid to reduce viscosity
D. Fluids prevent hypotension from anesthetic agents only
Correct Answer: B
Rationale: In cardiac tamponade, intrapericardial pressure exceeds ventricular filling pressure, severely restricting
preload. The compensatory mechanism is tachycardia and increased filling pressure to maintain cardiac output. IV fluids
transiently augment venous return, increasing right atrial pressure above intrapericardial pressure to maintain ventricular
filling gradient. Fluids do NOT improve contractility or alter pericardial fluid viscosity. This is a temporizing bridge to
definitive pericardiocentesis — the only intervention that addresses the underlying pathology. Excessive fluid can
precipitate right ventricular failure in chronic tamponade, so judicious boluses (250 mL aliquots) are recommended.
Q5: A 58-year-old male presents with sudden, tearing chest pain radiating to his back between the
scapulae. BP is 168/98 in the right arm and 142/88 in the left arm (differential >20 mmHg). CT
angiography reveals an aortic dissection involving the ascending aorta with the intimal tear at the
sinotubular junction. According to the Stanford classification, which type is this and what is the priority
management?
A. Stanford Type B — medical management with IV beta-blockers and analgesia
B. Stanford Type A — emergent surgical repair [CORRECT]
C. Stanford Type B — endovascular stent graft placement
D. Stanford Type A — aggressive BP control with IV nitroprusside only
Correct Answer: B
Rationale: The Stanford classification divides aortic dissections into Type A (involving the ascending aorta, regardless
of tear origin) and Type B (limited to the descending aorta distal to the left subclavian artery). Type A dissections are
surgical emergencies due to risk of rupture into the pericardium causing tamponade, acute aortic regurgitation, coronary
artery occlusion, or stroke — mortality increases 1-2% per hour without repair. Type B dissections are managed
medically with IV beta-blockers to reduce shear stress (target HR <60, SBP 100-120). Endovascular repair is reserved
for complicated Type B dissections with malperfusion, rupture, or expansion.
Page 3 | NUR265 Exam 3 — 100% Verified Answers
, NUR265 Exam 3 — Advanced Medical-Surgical Nursing (2026/2027 Update) Galen College of Nursing
Q6: A 64-year-old female with a Stanford Type B aortic dissection is admitted to the ICU. BP is 178/105,
HR 112. The nurse anticipates initiation of IV labetalol. Which BEST explains the rationale for
beta-blockade BEFORE initiating vasodilators like nicardipine or nitroprusside in acute aortic dissection?
A. Beta-blockers reduce the dP/dt (rate of pressure rise) to decrease shear stress on the intimal tear
[CORRECT]
B. Vasodilators cause reflex tachycardia that worsens dissection propagation
C. Beta-blockers prevent renal artery involvement in Type B dissections
D. Vasodilators are contraindicated in hypertensive patients over 60
Correct Answer: A
Rationale: In acute aortic dissection, the priority is reducing the rate of pressure rise (dP/dt) — the shear force that
propagates the intimal tear. IV beta-blockers (esmolol or labetalol) are first-line to achieve HR <60 and SBP 100-120.
Initiating pure vasodilators (nitroprusside, nicardipine) WITHOUT prior beta-blockade causes reflex tachycardia, which
increases dP/dt and accelerates dissection propagation — a critical error. If vasodilators are needed after adequate
beta-blockade, they are added as second-line agents. Esmolol is preferred in unstable patients due to its short half-term
(9 minutes) allowing rapid titration.
Q7: A 72-year-old male with severe aortic stenosis (AVA 0.6 cm², mean gradient 50 mmHg) presents with
exertional angina, syncope, and heart failure. He reports symptoms have worsened over 3 months. Which
intervention offers the ONLY definitive treatment with proven mortality benefit?
A. Balloon aortic valvuloplasty to relieve stenosis
B. Medical management with beta-blockers and diuretics
C. Transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR)
[CORRECT]
D. Dual antiplatelet therapy with aspirin and clopidogrel
Correct Answer: C
Rationale: Severe symptomatic aortic stenosis with the classic triad (angina, syncope, heart failure) carries a 50%
2-year mortality without valve replacement. TAVR (for patients ≥65 or high surgical risk) and SAVR (younger,
lower-risk patients) are the only definitive treatments with proven mortality benefit. Balloon valvuloplasty provides only
transient relief (weeks to months) and is reserved as a bridge in critically ill patients. Medical therapy does not alter
disease progression. Once symptoms develop, mean survival is 2-3 years without intervention, with sudden cardiac death
accounting for 20% of mortality.
Page 4 | NUR265 Exam 3 — 100% Verified Answers
