,NURS 480 Exam 2 — Advanced Medical-Surgical Nursing
Original Practice Questions 1–20 | Answers & Detailed Rationales
1. A patient taking warfarin has an INR of 6.8 and reports bleeding gums. Which action should
the nurse take first?
A. Administer the next scheduled dose
B. Hold warfarin and notify the provider
C. Encourage foods high in vitamin K without further assessment
D. Encourage vigorous exercise
Answer: B
Rationale: A markedly elevated INR with active bleeding indicates increased hemorrhage risk.
Warfarin should be held and the patient promptly evaluated for appropriate reversal or other
treatment.
2. Which laboratory test is used routinely to monitor the therapeutic effect of warfarin?
A. aPTT
B. Troponin
C. INR
D. Serum sodium
Answer: C
Rationale: The international normalized ratio (INR) is used to monitor warfarin therapy and
guide dose adjustments.
3. A patient taking warfarin asks why maintaining a consistent intake of vitamin K is important.
What is the best response?
A. Vitamin K increases the absorption of warfarin
B. Sudden changes in vitamin K intake can alter warfarin's anticoagulant effect
C. Vitamin K permanently prevents bleeding
D. Vitamin K makes warfarin ineffective in every patient
Answer: B
,Rationale: Warfarin interferes with vitamin-K-dependent clotting factor synthesis. Large
changes in dietary vitamin K can change the anticoagulant response, so consistency is
important.
4. Which ECG finding is most characteristic of atrial fibrillation?
A. Regular rhythm with identical P waves
B. Irregularly irregular rhythm with no consistent P waves
C. Wide QRS complexes occurring at exactly regular intervals
D. Complete absence of ventricular activity
Answer: B
Rationale: Atrial fibrillation produces chaotic atrial electrical activity and an irregularly irregular
ventricular rhythm.
5. A patient with atrial fibrillation suddenly develops severe hypotension and altered mental
status. What should the nurse anticipate?
A. Immediate synchronized cardioversion
B. Routine outpatient follow-up
C. Oral fluids only
D. Delayed treatment until the next shift
Answer: A
Rationale: Atrial fibrillation accompanied by hemodynamic instability may require synchronized
cardioversion.
6. A patient receiving IV potassium reports burning at the IV site. What should the nurse do
first?
A. Increase the infusion rate
B. Assess the IV site and stop the infusion if infiltration/extravasation is suspected
C. Apply a heating pad and continue the infusion
D. Flush rapidly with potassium solution
Answer: B
, Rationale: IV potassium is irritating and can cause serious tissue injury if extravasated. The
infusion site must be assessed promptly.
7. A patient has a serum potassium of 6.9 mEq/L and peaked T waves. Which intervention
should the nurse anticipate?
A. IV calcium to stabilize the cardiac membrane
B. Oral potassium supplementation
C. Encourage potassium-rich foods
D. Delay treatment until the next laboratory draw
Answer: A
Rationale: Severe hyperkalemia with ECG changes is a cardiac emergency. IV calcium may be
used to stabilize the myocardium while other treatments lower serum potassium.
8. Which finding is most concerning in a patient with hypokalemia?
A. Muscle weakness with ventricular dysrhythmias
B. Increased appetite
C. Warm skin
D. Mild thirst
Answer: A
Rationale: Significant potassium depletion can cause muscle weakness and dangerous cardiac
conduction abnormalities.
9. A patient prescribed sublingual nitroglycerin reports severe chest pain. Which instruction is
appropriate?
A. Swallow the tablet whole
B. Place the tablet under the tongue and allow it to dissolve
C. Take it only after eating a large meal
D. Crush it and mix it with water
Answer: B
Rationale: Sublingual nitroglycerin is placed under the tongue for rapid absorption.
Original Practice Questions 1–20 | Answers & Detailed Rationales
1. A patient taking warfarin has an INR of 6.8 and reports bleeding gums. Which action should
the nurse take first?
A. Administer the next scheduled dose
B. Hold warfarin and notify the provider
C. Encourage foods high in vitamin K without further assessment
D. Encourage vigorous exercise
Answer: B
Rationale: A markedly elevated INR with active bleeding indicates increased hemorrhage risk.
Warfarin should be held and the patient promptly evaluated for appropriate reversal or other
treatment.
2. Which laboratory test is used routinely to monitor the therapeutic effect of warfarin?
A. aPTT
B. Troponin
C. INR
D. Serum sodium
Answer: C
Rationale: The international normalized ratio (INR) is used to monitor warfarin therapy and
guide dose adjustments.
3. A patient taking warfarin asks why maintaining a consistent intake of vitamin K is important.
What is the best response?
A. Vitamin K increases the absorption of warfarin
B. Sudden changes in vitamin K intake can alter warfarin's anticoagulant effect
C. Vitamin K permanently prevents bleeding
D. Vitamin K makes warfarin ineffective in every patient
Answer: B
,Rationale: Warfarin interferes with vitamin-K-dependent clotting factor synthesis. Large
changes in dietary vitamin K can change the anticoagulant response, so consistency is
important.
4. Which ECG finding is most characteristic of atrial fibrillation?
A. Regular rhythm with identical P waves
B. Irregularly irregular rhythm with no consistent P waves
C. Wide QRS complexes occurring at exactly regular intervals
D. Complete absence of ventricular activity
Answer: B
Rationale: Atrial fibrillation produces chaotic atrial electrical activity and an irregularly irregular
ventricular rhythm.
5. A patient with atrial fibrillation suddenly develops severe hypotension and altered mental
status. What should the nurse anticipate?
A. Immediate synchronized cardioversion
B. Routine outpatient follow-up
C. Oral fluids only
D. Delayed treatment until the next shift
Answer: A
Rationale: Atrial fibrillation accompanied by hemodynamic instability may require synchronized
cardioversion.
6. A patient receiving IV potassium reports burning at the IV site. What should the nurse do
first?
A. Increase the infusion rate
B. Assess the IV site and stop the infusion if infiltration/extravasation is suspected
C. Apply a heating pad and continue the infusion
D. Flush rapidly with potassium solution
Answer: B
, Rationale: IV potassium is irritating and can cause serious tissue injury if extravasated. The
infusion site must be assessed promptly.
7. A patient has a serum potassium of 6.9 mEq/L and peaked T waves. Which intervention
should the nurse anticipate?
A. IV calcium to stabilize the cardiac membrane
B. Oral potassium supplementation
C. Encourage potassium-rich foods
D. Delay treatment until the next laboratory draw
Answer: A
Rationale: Severe hyperkalemia with ECG changes is a cardiac emergency. IV calcium may be
used to stabilize the myocardium while other treatments lower serum potassium.
8. Which finding is most concerning in a patient with hypokalemia?
A. Muscle weakness with ventricular dysrhythmias
B. Increased appetite
C. Warm skin
D. Mild thirst
Answer: A
Rationale: Significant potassium depletion can cause muscle weakness and dangerous cardiac
conduction abnormalities.
9. A patient prescribed sublingual nitroglycerin reports severe chest pain. Which instruction is
appropriate?
A. Swallow the tablet whole
B. Place the tablet under the tongue and allow it to dissolve
C. Take it only after eating a large meal
D. Crush it and mix it with water
Answer: B
Rationale: Sublingual nitroglycerin is placed under the tongue for rapid absorption.
