,West Coast NURS 480 Exam 2 | Advanced Medical-Surgical
Nursing (2026) Q&A
1. A client with acute decompensated heart failure has a potassium level of 2.4
mEq/L. Which medication should the nurse identify as the most likely cause of this
electrolyte imbalance?
A) Furosemide
B) Nitroglycerin
C) Metoprolol
D) Spironolactone
Correct Answer: A) Furosemide
Rationale: Furosemide is a loop diuretic that causes potassium wasting by inhibiting
sodium reabsorption in the ascending loop of Henle, leading to increased potassium
excretion. A potassium level of 2.4 mEq/L is critically low and requires immediate
intervention. Spironolactone is potassium-sparing and would not cause hypokalemia.
2. A client with atrial fibrillation who is taking warfarin has an INR of 4.5. Which action
should the nurse take?
A) Administer the next dose of warfarin as prescribed
B) Report the result to the provider immediately
C) Document the finding as therapeutic
D) Encourage increased intake of vitamin K-rich foods
Correct Answer: B) Report the result to the provider immediately
,Rationale: The therapeutic INR range for atrial fibrillation is typically 2.0 to 3.0. An
INR of 4.5 indicates a significant risk of bleeding and requires immediate provider
notification for possible dose adjustment or administration of vitamin K.
3. A nurse is performing a neurological assessment on a client with head trauma.
Which assessment evaluates the function of cranial nerve III?
A) Instruct the client to smile and show teeth
B) Ask the client to identify a familiar scent
C) Instruct the client to look up and down without moving the head
D) Assess the client's ability to hear a whispered voice
Correct Answer: C) Instruct the client to look up and down without moving the head
Rationale: Cranial nerve III (oculomotor) controls most eye movements, including
upward and downward gaze, as well as pupillary constriction. Testing vertical gaze
assesses CN III function. CN VII controls facial expressions, CN I controls smell, and
CN VIII controls hearing.
4. A nurse is caring for a client who develops ventricular fibrillation. The client is
unresponsive, pulseless, and apneic. Which action should the nurse take first?
A) Administer epinephrine intravenously
B) Begin chest compressions
C) Defibrillate the client
D) Establish IV access
Correct Answer: C) Defibrillate the client
Rationale: Ventricular fibrillation is a pulseless, life-threatening rhythm. The priority
intervention is immediate defibrillation, as it is the most effective treatment for
, terminating V-fib and restoring a perfusing rhythm. CPR should be initiated while the
defibrillator is being prepared.
5. A client who had an acute myocardial infarction asks when sexual intercourse can
be resumed. Which response by the nurse is most appropriate?
A) "You should wait at least six months before resuming sexual activity."
B) "Sexual activity uses about as much energy as climbing two flights of stairs."
C) "You will never be able to resume sexual activity safely."
D) "You can resume sexual activity immediately without any restrictions."
Correct Answer: B) "Sexual activity uses about as much energy as climbing two
flights of stairs."
Rationale: Sexual activity requires approximately the same energy expenditure as
climbing two flights of stairs. If the client can climb two flights of stairs without
symptoms, sexual activity is generally safe to resume. This provides a practical,
evidence-based guideline for the client.
6. A nurse is caring for a client who had a permanent pacemaker inserted. Which
prescription should the nurse clarify with the provider?
A) Chest X-ray to verify lead placement
B) MRI of the chest
C) ECG monitoring
D) Wound care instructions
Correct Answer: B) MRI of the chest
Nursing (2026) Q&A
1. A client with acute decompensated heart failure has a potassium level of 2.4
mEq/L. Which medication should the nurse identify as the most likely cause of this
electrolyte imbalance?
A) Furosemide
B) Nitroglycerin
C) Metoprolol
D) Spironolactone
Correct Answer: A) Furosemide
Rationale: Furosemide is a loop diuretic that causes potassium wasting by inhibiting
sodium reabsorption in the ascending loop of Henle, leading to increased potassium
excretion. A potassium level of 2.4 mEq/L is critically low and requires immediate
intervention. Spironolactone is potassium-sparing and would not cause hypokalemia.
2. A client with atrial fibrillation who is taking warfarin has an INR of 4.5. Which action
should the nurse take?
A) Administer the next dose of warfarin as prescribed
B) Report the result to the provider immediately
C) Document the finding as therapeutic
D) Encourage increased intake of vitamin K-rich foods
Correct Answer: B) Report the result to the provider immediately
,Rationale: The therapeutic INR range for atrial fibrillation is typically 2.0 to 3.0. An
INR of 4.5 indicates a significant risk of bleeding and requires immediate provider
notification for possible dose adjustment or administration of vitamin K.
3. A nurse is performing a neurological assessment on a client with head trauma.
Which assessment evaluates the function of cranial nerve III?
A) Instruct the client to smile and show teeth
B) Ask the client to identify a familiar scent
C) Instruct the client to look up and down without moving the head
D) Assess the client's ability to hear a whispered voice
Correct Answer: C) Instruct the client to look up and down without moving the head
Rationale: Cranial nerve III (oculomotor) controls most eye movements, including
upward and downward gaze, as well as pupillary constriction. Testing vertical gaze
assesses CN III function. CN VII controls facial expressions, CN I controls smell, and
CN VIII controls hearing.
4. A nurse is caring for a client who develops ventricular fibrillation. The client is
unresponsive, pulseless, and apneic. Which action should the nurse take first?
A) Administer epinephrine intravenously
B) Begin chest compressions
C) Defibrillate the client
D) Establish IV access
Correct Answer: C) Defibrillate the client
Rationale: Ventricular fibrillation is a pulseless, life-threatening rhythm. The priority
intervention is immediate defibrillation, as it is the most effective treatment for
, terminating V-fib and restoring a perfusing rhythm. CPR should be initiated while the
defibrillator is being prepared.
5. A client who had an acute myocardial infarction asks when sexual intercourse can
be resumed. Which response by the nurse is most appropriate?
A) "You should wait at least six months before resuming sexual activity."
B) "Sexual activity uses about as much energy as climbing two flights of stairs."
C) "You will never be able to resume sexual activity safely."
D) "You can resume sexual activity immediately without any restrictions."
Correct Answer: B) "Sexual activity uses about as much energy as climbing two
flights of stairs."
Rationale: Sexual activity requires approximately the same energy expenditure as
climbing two flights of stairs. If the client can climb two flights of stairs without
symptoms, sexual activity is generally safe to resume. This provides a practical,
evidence-based guideline for the client.
6. A nurse is caring for a client who had a permanent pacemaker inserted. Which
prescription should the nurse clarify with the provider?
A) Chest X-ray to verify lead placement
B) MRI of the chest
C) ECG monitoring
D) Wound care instructions
Correct Answer: B) MRI of the chest
