Galen NUR 242 | Med-Surg Nursing | Exam 4 (2026/2027) A+ Guarantee | Practice Questions & Study Guide
Galen NUR 242 | Med-Surg Nursing | Exam 4
Comprehensive Practice Exam (A+ Guarantee)
110 Advanced Practice Questions with Detailed Rationales
Cognitive Levels: 25% Recall | 50% Application | 25% Analysis • Format: 75% Scenario-Based, 25% Direct Recall
How to Use This Study Guide: Each question is followed by four options (A-D). The correct option is marked
[CORRECT] in green. A detailed rationale explains the advanced medical-surgical reasoning, including pathophysiology,
assessment priorities, advanced interventions, and clinical judgment — serving double duty as exam practice and study
content. The competency label identifies the NUR 242 domain being assessed. Work through all 110 questions, review
rationales for both correct and incorrect answers, and revisit sections where you missed multiple questions. Commonly
confused concept pairs (DKA vs. HHS, SIADH vs. DI, ARDS vs. Pulmonary Edema, DIC vs. HIT, Respiratory vs. Metabolic
Acidosis) are highlighted throughout for targeted review.
Exam Sections Overview
Section 1: Advanced Cardiovascular and Hematologic Nursing (Q1-18)
Section 2: Advanced Respiratory and Acid-Base Nursing (Q19-34)
Section 3: Advanced Neurological and Sensory Nursing (Q35-49)
Section 4: Advanced Renal and Genitourinary Nursing (Q50-63)
Section 5: Advanced Endocrine and Metabolic Nursing (Q64-77)
Section 6: Advanced Gastrointestinal and Hepatic Nursing (Q78-91)
Section 7: Oncologic, Immunologic, and Palliative Nursing (Q92-101)
Section 8: Complex Prioritization, Emergency Management, and Clinical Judgment (Q102-110)
Page 1
,Galen NUR 242 | Med-Surg Nursing | Exam 4 (2026/2027) A+ Guarantee | Practice Questions & Study Guide
Section 1: Advanced Cardiovascular and Hematologic Nursing
Heart Failure, Dysrhythmias, Coagulopathies, & Transfusion Therapy | Questions 1-18
Q1: A 68-year-old patient with systolic heart failure (HFrEF, EF 28%) is receiving IV furosemide.
The patient reports muscle weakness and cramping. Morning labs: K+ 3.0 mEq/L, Mg 1.4 mg/dL.
Which action by the nurse is most appropriate?
A. Continue the furosemide and reassess potassium in the morning
B. Hold the next furosemide dose, notify the provider, and prepare to administer IV potassium and
magnesium replacements [CORRECT]
C. Increase the furosemide dose to address potential fluid overload
D. Administer oral potassium alone and continue the furosemide at the current rate
Correct Answer: B
Rationale: Hypokalemia (K+ < 3.5) in a heart failure patient on loop diuretics is dangerous because it potentiates digoxin
toxicity and increases the risk of ventricular dysrhythmias. Concurrent hypomagnesemia (Mg < 1.7) makes potassium
repletion ineffective because magnesium is required for potassium retention. Holding the diuretic and replacing both
electrolytes IV is the priority. Option A delays intervention; option C worsens the loss; option D ignores the magnesium
deficit, making potassium replacement ineffective. Study tip: always correct magnesium first or with potassium — "no Mg, no
K."
Competency: Heart Failure Pharmacology | Cognitive: Application
Q2: A patient with acute decompensated heart failure has a pulmonary artery catheter showing
PCWP 28 mmHg (normal 6-12), CI 1.8 L/min/m² (normal 2.5-4.0), and SVR 1800 dynes (normal
800-1200). This hemodynamic profile is best described as:
A. Warm and dry (compensated)
B. Warm and wet (volume overloaded with preserved output)
C. Cold and wet (cardiogenic shock physiology with volume overload) [CORRECT]
D. Cold and dry (hypovolemic shock)
Correct Answer: C
Rationale: This is the Forrester/Stevenson hemodynamic subset "cold and wet": high PCWP (wet — volume overload) plus
low cardiac index (cold — poor perfusion). This represents cardiogenic shock physiology requiring inotropes (dobutamine,
milrinone) plus diuresis, and possibly mechanical support. Option B (warm and wet) would have a normal or high CI. Option
D (cold and dry) has low PCWP. Study tip: "cold" = low CI; "wet" = high PCWP; the worst combination is cold and wet.
Competency: HF Hemodynamic Profiles | Cognitive: Analysis
Page 2
,Galen NUR 242 | Med-Surg Nursing | Exam 4 (2026/2027) A+ Guarantee | Practice Questions & Study Guide
Q3: A patient with chronic atrial fibrillation has a heart rate of 152 bpm at rest. The nurse prepares
to administer IV diltiazem. Which assessment finding is the most important to monitor during
administration?
A. Respiratory rate and oxygen saturation
B. Blood pressure and heart rate, as diltiazem can cause hypotension and bradycardia [CORRECT]
C. Temperature and white blood cell count
D. Level of consciousness and pupil response
Correct Answer: B
Rationale: IV diltiazem (a non-dihydropyridine CCB) rapidly slows AV node conduction, controlling ventricular response in
atrial fibrillation. However, it is a negative inotrope and vasodilator, so the critical monitoring parameters are blood pressure
(hypotension risk) and heart rate (bradycardia/asystole risk). Have IV calcium gluconate and atropine available. Option A is
important but secondary. Options C and D are not directly affected by diltiazem. Study tip: rate-control agents (diltiazem,
metoprolol) require continuous ECG and frequent BP during IV push.
Competency: AFib Rate Control | Cognitive: Application
Q4: The cardiac monitor shows a regular, narrow-complex tachycardia at 180 bpm with no visible
P waves. The patient is alert, BP 110/70. Which intervention should the nurse attempt FIRST per
ACLS?
A. Immediate synchronized cardioversion at 100 joules
B. Vagal maneuvers (e.g., Valsalva, carotid sinus massage) followed by IV adenosine if unsuccessful
[CORRECT]
C. IV amiodarone 150 mg over 10 minutes
D. IV diltiazem 0.25 mg/kg bolus
Correct Answer: B
Rationale: This rhythm is consistent with paroxysmal supraventricular tachycardia (PSVT). For a hemodynamically stable
patient, ACLS recommends vagal maneuvers first (Valsalva, modified Valsalva, carotid massage if no bruits), then IV
adenosine 6 mg rapid push followed by a 12 mg dose if needed. Synchronized cardioversion (option A) is reserved for
unstable patients (hypotension, altered mental status, chest pain, acute heart failure). Options C and D are second-line or
alternative agents. Study tip: adenosine must be pushed fast (over 1-2 seconds) followed by a 20 mL saline flush; warn the
patient about the brief sense of doom.
Competency: PSVT Management (ACLS) | Cognitive: Application
Page 3
, Galen NUR 242 | Med-Surg Nursing | Exam 4 (2026/2027) A+ Guarantee | Practice Questions & Study Guide
Q5: A patient on a heparin infusion for a DVT has a platelet count that dropped from 280,000 to
110,000 over 5 days, with a new thrombotic event. Which condition is most likely, and what is the
priority action?
A. DIC; discontinue heparin and administer fresh frozen plasma
B. Heparin-induced thrombocytopenia (HIT); immediately discontinue all heparin products and start a
non-heparin anticoagulant such as argatroban [CORRECT]
C. Idiopathic thrombocytopenic purpura (ITP); administer IVIG and continue heparin
D. Splenic sequestration; consult surgery for possible splenectomy
Correct Answer: B
Rationale: The 50%+ platelet drop with a new thrombosis 5-10 days after heparin exposure is the classic presentation of HIT
type II, an immune-mediated (IgG anti-PF4) disorder causing paradoxical thrombosis. The priority is immediate
discontinuation of ALL heparin (including flushes, LMWH) and initiation of a direct thrombin inhibitor (argatroban,
bivalirudin) or fondaparinux. Warfarin alone is contraindicated initially because it can cause skin necrosis and venous limb
gangrene in HIT. DIC (option A) would show prolonged PT/aPTT, low fibrinogen, and fragmented RBCs. ITP (option C) is
not associated with heparin. Study tip: HIT = thrombocytopenia PLUS thrombosis (paradoxical).
Competency: HIT Recognition | Cognitive: Analysis
Q6: A patient with septic shock develops DIC. Labs show PT 28 sec (INR 3.2), aPTT 65 sec,
platelets 45,000, fibrinogen 90 mg/dL, and D-dimer markedly elevated. The patient is oozing from
IV sites. Which order should the nurse anticipate?
A. Administer aspirin and heparin to prevent further clotting
B. Transfuse platelets, fresh frozen plasma (FFP), and cryoprecipitate to replace consumed factors and
control bleeding [CORRECT]
C. Administer IV vitamin K and protamine sulfate
D. Initiate therapeutic hypothermia to slow metabolism
Correct Answer: B
Rationale: DIC involves widespread microvascular clotting leading to consumption of platelets and clotting factors, resulting
in simultaneous bleeding and thrombosis. With active bleeding and severe factor depletion (low fibrinogen, prolonged
PT/aPTT, thrombocytopenia), the priority is replacement therapy: platelets, FFP (for clotting factors), and cryoprecipitate (for
fibrinogen). Heparin (option A) may be considered only in thrombosis-dominant DIC without bleeding. Options C and D are
not appropriate for DIC. Study tip: "treat the underlying cause" (sepsis) is essential; transfusion is supportive.
Competency: DIC Management | Cognitive: Application
Page 4
Galen NUR 242 | Med-Surg Nursing | Exam 4
Comprehensive Practice Exam (A+ Guarantee)
110 Advanced Practice Questions with Detailed Rationales
Cognitive Levels: 25% Recall | 50% Application | 25% Analysis • Format: 75% Scenario-Based, 25% Direct Recall
How to Use This Study Guide: Each question is followed by four options (A-D). The correct option is marked
[CORRECT] in green. A detailed rationale explains the advanced medical-surgical reasoning, including pathophysiology,
assessment priorities, advanced interventions, and clinical judgment — serving double duty as exam practice and study
content. The competency label identifies the NUR 242 domain being assessed. Work through all 110 questions, review
rationales for both correct and incorrect answers, and revisit sections where you missed multiple questions. Commonly
confused concept pairs (DKA vs. HHS, SIADH vs. DI, ARDS vs. Pulmonary Edema, DIC vs. HIT, Respiratory vs. Metabolic
Acidosis) are highlighted throughout for targeted review.
Exam Sections Overview
Section 1: Advanced Cardiovascular and Hematologic Nursing (Q1-18)
Section 2: Advanced Respiratory and Acid-Base Nursing (Q19-34)
Section 3: Advanced Neurological and Sensory Nursing (Q35-49)
Section 4: Advanced Renal and Genitourinary Nursing (Q50-63)
Section 5: Advanced Endocrine and Metabolic Nursing (Q64-77)
Section 6: Advanced Gastrointestinal and Hepatic Nursing (Q78-91)
Section 7: Oncologic, Immunologic, and Palliative Nursing (Q92-101)
Section 8: Complex Prioritization, Emergency Management, and Clinical Judgment (Q102-110)
Page 1
,Galen NUR 242 | Med-Surg Nursing | Exam 4 (2026/2027) A+ Guarantee | Practice Questions & Study Guide
Section 1: Advanced Cardiovascular and Hematologic Nursing
Heart Failure, Dysrhythmias, Coagulopathies, & Transfusion Therapy | Questions 1-18
Q1: A 68-year-old patient with systolic heart failure (HFrEF, EF 28%) is receiving IV furosemide.
The patient reports muscle weakness and cramping. Morning labs: K+ 3.0 mEq/L, Mg 1.4 mg/dL.
Which action by the nurse is most appropriate?
A. Continue the furosemide and reassess potassium in the morning
B. Hold the next furosemide dose, notify the provider, and prepare to administer IV potassium and
magnesium replacements [CORRECT]
C. Increase the furosemide dose to address potential fluid overload
D. Administer oral potassium alone and continue the furosemide at the current rate
Correct Answer: B
Rationale: Hypokalemia (K+ < 3.5) in a heart failure patient on loop diuretics is dangerous because it potentiates digoxin
toxicity and increases the risk of ventricular dysrhythmias. Concurrent hypomagnesemia (Mg < 1.7) makes potassium
repletion ineffective because magnesium is required for potassium retention. Holding the diuretic and replacing both
electrolytes IV is the priority. Option A delays intervention; option C worsens the loss; option D ignores the magnesium
deficit, making potassium replacement ineffective. Study tip: always correct magnesium first or with potassium — "no Mg, no
K."
Competency: Heart Failure Pharmacology | Cognitive: Application
Q2: A patient with acute decompensated heart failure has a pulmonary artery catheter showing
PCWP 28 mmHg (normal 6-12), CI 1.8 L/min/m² (normal 2.5-4.0), and SVR 1800 dynes (normal
800-1200). This hemodynamic profile is best described as:
A. Warm and dry (compensated)
B. Warm and wet (volume overloaded with preserved output)
C. Cold and wet (cardiogenic shock physiology with volume overload) [CORRECT]
D. Cold and dry (hypovolemic shock)
Correct Answer: C
Rationale: This is the Forrester/Stevenson hemodynamic subset "cold and wet": high PCWP (wet — volume overload) plus
low cardiac index (cold — poor perfusion). This represents cardiogenic shock physiology requiring inotropes (dobutamine,
milrinone) plus diuresis, and possibly mechanical support. Option B (warm and wet) would have a normal or high CI. Option
D (cold and dry) has low PCWP. Study tip: "cold" = low CI; "wet" = high PCWP; the worst combination is cold and wet.
Competency: HF Hemodynamic Profiles | Cognitive: Analysis
Page 2
,Galen NUR 242 | Med-Surg Nursing | Exam 4 (2026/2027) A+ Guarantee | Practice Questions & Study Guide
Q3: A patient with chronic atrial fibrillation has a heart rate of 152 bpm at rest. The nurse prepares
to administer IV diltiazem. Which assessment finding is the most important to monitor during
administration?
A. Respiratory rate and oxygen saturation
B. Blood pressure and heart rate, as diltiazem can cause hypotension and bradycardia [CORRECT]
C. Temperature and white blood cell count
D. Level of consciousness and pupil response
Correct Answer: B
Rationale: IV diltiazem (a non-dihydropyridine CCB) rapidly slows AV node conduction, controlling ventricular response in
atrial fibrillation. However, it is a negative inotrope and vasodilator, so the critical monitoring parameters are blood pressure
(hypotension risk) and heart rate (bradycardia/asystole risk). Have IV calcium gluconate and atropine available. Option A is
important but secondary. Options C and D are not directly affected by diltiazem. Study tip: rate-control agents (diltiazem,
metoprolol) require continuous ECG and frequent BP during IV push.
Competency: AFib Rate Control | Cognitive: Application
Q4: The cardiac monitor shows a regular, narrow-complex tachycardia at 180 bpm with no visible
P waves. The patient is alert, BP 110/70. Which intervention should the nurse attempt FIRST per
ACLS?
A. Immediate synchronized cardioversion at 100 joules
B. Vagal maneuvers (e.g., Valsalva, carotid sinus massage) followed by IV adenosine if unsuccessful
[CORRECT]
C. IV amiodarone 150 mg over 10 minutes
D. IV diltiazem 0.25 mg/kg bolus
Correct Answer: B
Rationale: This rhythm is consistent with paroxysmal supraventricular tachycardia (PSVT). For a hemodynamically stable
patient, ACLS recommends vagal maneuvers first (Valsalva, modified Valsalva, carotid massage if no bruits), then IV
adenosine 6 mg rapid push followed by a 12 mg dose if needed. Synchronized cardioversion (option A) is reserved for
unstable patients (hypotension, altered mental status, chest pain, acute heart failure). Options C and D are second-line or
alternative agents. Study tip: adenosine must be pushed fast (over 1-2 seconds) followed by a 20 mL saline flush; warn the
patient about the brief sense of doom.
Competency: PSVT Management (ACLS) | Cognitive: Application
Page 3
, Galen NUR 242 | Med-Surg Nursing | Exam 4 (2026/2027) A+ Guarantee | Practice Questions & Study Guide
Q5: A patient on a heparin infusion for a DVT has a platelet count that dropped from 280,000 to
110,000 over 5 days, with a new thrombotic event. Which condition is most likely, and what is the
priority action?
A. DIC; discontinue heparin and administer fresh frozen plasma
B. Heparin-induced thrombocytopenia (HIT); immediately discontinue all heparin products and start a
non-heparin anticoagulant such as argatroban [CORRECT]
C. Idiopathic thrombocytopenic purpura (ITP); administer IVIG and continue heparin
D. Splenic sequestration; consult surgery for possible splenectomy
Correct Answer: B
Rationale: The 50%+ platelet drop with a new thrombosis 5-10 days after heparin exposure is the classic presentation of HIT
type II, an immune-mediated (IgG anti-PF4) disorder causing paradoxical thrombosis. The priority is immediate
discontinuation of ALL heparin (including flushes, LMWH) and initiation of a direct thrombin inhibitor (argatroban,
bivalirudin) or fondaparinux. Warfarin alone is contraindicated initially because it can cause skin necrosis and venous limb
gangrene in HIT. DIC (option A) would show prolonged PT/aPTT, low fibrinogen, and fragmented RBCs. ITP (option C) is
not associated with heparin. Study tip: HIT = thrombocytopenia PLUS thrombosis (paradoxical).
Competency: HIT Recognition | Cognitive: Analysis
Q6: A patient with septic shock develops DIC. Labs show PT 28 sec (INR 3.2), aPTT 65 sec,
platelets 45,000, fibrinogen 90 mg/dL, and D-dimer markedly elevated. The patient is oozing from
IV sites. Which order should the nurse anticipate?
A. Administer aspirin and heparin to prevent further clotting
B. Transfuse platelets, fresh frozen plasma (FFP), and cryoprecipitate to replace consumed factors and
control bleeding [CORRECT]
C. Administer IV vitamin K and protamine sulfate
D. Initiate therapeutic hypothermia to slow metabolism
Correct Answer: B
Rationale: DIC involves widespread microvascular clotting leading to consumption of platelets and clotting factors, resulting
in simultaneous bleeding and thrombosis. With active bleeding and severe factor depletion (low fibrinogen, prolonged
PT/aPTT, thrombocytopenia), the priority is replacement therapy: platelets, FFP (for clotting factors), and cryoprecipitate (for
fibrinogen). Heparin (option A) may be considered only in thrombosis-dominant DIC without bleeding. Options C and D are
not appropriate for DIC. Study tip: "treat the underlying cause" (sepsis) is essential; transfusion is supportive.
Competency: DIC Management | Cognitive: Application
Page 4
