NUR 210 | NUR210 Exam 3 V2 – Updated and Latest Questions and
Correct Answers with Rationale – Galen College of Nursing
1. A patient taking digoxin for heart failure reports seeing yellow-green halos around lights.
The nurse notes a heart rate of 52 beats per minute. What is the most appropriate nursing
action?
A. Administer the next dose as scheduled.
B. Request a laboratory test for serum digoxin levels.
C. Hold the dose and notify the healthcare provider.
D. Assess the patient for signs of pulmonary edema.
Answer: C
Rationale: Digoxin is a cardiac glycoside that has a narrow therapeutic index and can cause
significant toxicity. The presence of visual disturbances like yellow halos combined with
bradycardia strongly suggests digitalis toxicity. Holding the medication prevents further
accumulation while the provider is alerted to order serum levels or interventions. Delaying
the report to wait for lab results could lead to worsening cardiac arrhythmias. Prioritizing
safety through immediate dose cessation is the standard nursing response for suspected
toxicity.
2. A nurse is preparing to administer enalapril to a patient with hypertension. Which
assessment finding should the nurse prioritize as a contraindication or reason for immediate
concern?
A. A history of a dry, hacking cough.
B. Swelling of the lips and tongue.
C. Serum potassium level of 3.8 mEq/L.
D. Blood pressure of 148/92 mmHg.
Answer: B
Rationale: Enalapril is an ACE inhibitor that can cause angioedema, a life-threatening
adverse reaction involving swelling of the upper airway. Swelling of the lips and tongue
indicates an immediate threat to the patient’s airway patency. While a dry cough is a
common side effect, it is not as acutely dangerous as angioedema. The potassium level is
within normal range, and the high blood pressure is an indication for the drug. Rapid
recognition of angioedema is crucial for preventing respiratory arrest.
,3. A patient receiving heparin via continuous IV infusion for a deep vein thrombosis has an
activated partial thromboplastin time (aPTT) of 110 seconds. What is the priority nursing
intervention?
A. Increase the infusion rate to meet therapeutic goals.
B. Maintain the current rate and reassess in 4 hours.
C. Stop the infusion and notify the provider.
D. Prepare to administer Vitamin K.
Answer: C
Rationale: Heparin is an anticoagulant monitored via aPTT, with a therapeutic range
typically being 1.5 to 2.5 times the control value. An aPTT of 110 seconds is significantly
above the therapeutic range, placing the patient at high risk for hemorrhage. Stopping the
infusion immediately limits further anticoagulation and allows the short half-life of heparin
to lower the level. Vitamin K is the antagonist for warfarin, not heparin, whereas protamine
sulfate would be the correct antidote for heparin if needed. Constant monitoring for signs
of bleeding is essential once the infusion is halted.
4. A patient is prescribed furosemide 40 mg IV push for acute pulmonary edema. Which
laboratory value should the nurse monitor most closely after administration?
A. Serum potassium
B. Serum sodium
C. Serum calcium
D. Serum magnesium
Answer: A
Rationale: Furosemide is a loop diuretic that causes significant excretion of water, sodium,
and potassium in the kidneys. Hypokalemia is a common and dangerous side effect that can
lead to life-threatening cardiac dysrhythmias. The rapid onset of IV furosemide requires
frequent monitoring of electrolytes to ensure levels do not drop dangerously low. While
other electrolytes are affected, potassium fluctuations have the most immediate impact on
cardiac stability. Supplementation or dietary changes may be necessary based on these
laboratory results.
5. A patient with type 1 diabetes mellitus is given 10 units of regular insulin at 0730. At what
time should the nurse be most alert for signs of hypoglycemia?
A. 0800 to 0830
B. 1600 to 1800
C. 1300 to 1500
D. 0930 to 1130
, Answer: D
Rationale: Regular insulin is a short-acting insulin with an onset of 30-60 minutes and a
peak effect occurring between 2 to 4 hours. Hypoglycemia is most likely to occur during the
peak time when the insulin concentration in the blood is at its highest. At 0930 to 1130, the
nurse must monitor for symptoms like diaphoresis, tremors, and confusion. Ensuring the
patient consumes an appropriate meal following administration is key to preventing this
dip. Understanding insulin kinetics allows the nurse to time assessments and interventions
effectively.
6. Which assessment finding in a patient taking spironolactone indicates a potential adverse
effect?
A. Serum potassium of 5.8 mEq/L
B. Serum sodium of 135 mEq/L
C. Blood pressure of 110/70 mmHg
D. Increased urinary output
Answer: A
Rationale: Spironolactone is a potassium-sparing diuretic that works by antagonizing
aldosterone in the distal tubules. A serum potassium level of 5.8 mEq/L indicates
hyperkalemia, which is a significant risk for patients on this medication. Excessive
potassium retention can lead to cardiac arrest if not addressed through medication
adjustment or dietary restriction. The other options are either therapeutic effects or within
normal ranges. Educating patients to avoid potassium-rich salt substitutes is a critical
nursing responsibility.
7. A patient is receiving vancomycin IV for a MRSA infection. During the infusion, the patient
develops flushing of the neck and chest and reports itching. What should the nurse do first?
A. Stop the infusion immediately and notify the provider.
B. Slow the rate of the infusion.
C. Administer intramuscular epinephrine.
D. Apply a cold compress to the affected areas.
Answer: B
Rationale: The patient is describing Red Man Syndrome, a common infusion-related
reaction caused by the rapid administration of vancomycin. Unlike a true allergic reaction,
this is managed by slowing the infusion rate rather than stopping it entirely. The flushing
and pruritus are mediated by histamine release but usually do not progress to anaphylaxis
if the rate is corrected. Epinephrine is reserved for anaphylactic shock, which involves
airway compromise or hypotension. The nurse should continue to monitor the patient
closely for further changes in status.
Correct Answers with Rationale – Galen College of Nursing
1. A patient taking digoxin for heart failure reports seeing yellow-green halos around lights.
The nurse notes a heart rate of 52 beats per minute. What is the most appropriate nursing
action?
A. Administer the next dose as scheduled.
B. Request a laboratory test for serum digoxin levels.
C. Hold the dose and notify the healthcare provider.
D. Assess the patient for signs of pulmonary edema.
Answer: C
Rationale: Digoxin is a cardiac glycoside that has a narrow therapeutic index and can cause
significant toxicity. The presence of visual disturbances like yellow halos combined with
bradycardia strongly suggests digitalis toxicity. Holding the medication prevents further
accumulation while the provider is alerted to order serum levels or interventions. Delaying
the report to wait for lab results could lead to worsening cardiac arrhythmias. Prioritizing
safety through immediate dose cessation is the standard nursing response for suspected
toxicity.
2. A nurse is preparing to administer enalapril to a patient with hypertension. Which
assessment finding should the nurse prioritize as a contraindication or reason for immediate
concern?
A. A history of a dry, hacking cough.
B. Swelling of the lips and tongue.
C. Serum potassium level of 3.8 mEq/L.
D. Blood pressure of 148/92 mmHg.
Answer: B
Rationale: Enalapril is an ACE inhibitor that can cause angioedema, a life-threatening
adverse reaction involving swelling of the upper airway. Swelling of the lips and tongue
indicates an immediate threat to the patient’s airway patency. While a dry cough is a
common side effect, it is not as acutely dangerous as angioedema. The potassium level is
within normal range, and the high blood pressure is an indication for the drug. Rapid
recognition of angioedema is crucial for preventing respiratory arrest.
,3. A patient receiving heparin via continuous IV infusion for a deep vein thrombosis has an
activated partial thromboplastin time (aPTT) of 110 seconds. What is the priority nursing
intervention?
A. Increase the infusion rate to meet therapeutic goals.
B. Maintain the current rate and reassess in 4 hours.
C. Stop the infusion and notify the provider.
D. Prepare to administer Vitamin K.
Answer: C
Rationale: Heparin is an anticoagulant monitored via aPTT, with a therapeutic range
typically being 1.5 to 2.5 times the control value. An aPTT of 110 seconds is significantly
above the therapeutic range, placing the patient at high risk for hemorrhage. Stopping the
infusion immediately limits further anticoagulation and allows the short half-life of heparin
to lower the level. Vitamin K is the antagonist for warfarin, not heparin, whereas protamine
sulfate would be the correct antidote for heparin if needed. Constant monitoring for signs
of bleeding is essential once the infusion is halted.
4. A patient is prescribed furosemide 40 mg IV push for acute pulmonary edema. Which
laboratory value should the nurse monitor most closely after administration?
A. Serum potassium
B. Serum sodium
C. Serum calcium
D. Serum magnesium
Answer: A
Rationale: Furosemide is a loop diuretic that causes significant excretion of water, sodium,
and potassium in the kidneys. Hypokalemia is a common and dangerous side effect that can
lead to life-threatening cardiac dysrhythmias. The rapid onset of IV furosemide requires
frequent monitoring of electrolytes to ensure levels do not drop dangerously low. While
other electrolytes are affected, potassium fluctuations have the most immediate impact on
cardiac stability. Supplementation or dietary changes may be necessary based on these
laboratory results.
5. A patient with type 1 diabetes mellitus is given 10 units of regular insulin at 0730. At what
time should the nurse be most alert for signs of hypoglycemia?
A. 0800 to 0830
B. 1600 to 1800
C. 1300 to 1500
D. 0930 to 1130
, Answer: D
Rationale: Regular insulin is a short-acting insulin with an onset of 30-60 minutes and a
peak effect occurring between 2 to 4 hours. Hypoglycemia is most likely to occur during the
peak time when the insulin concentration in the blood is at its highest. At 0930 to 1130, the
nurse must monitor for symptoms like diaphoresis, tremors, and confusion. Ensuring the
patient consumes an appropriate meal following administration is key to preventing this
dip. Understanding insulin kinetics allows the nurse to time assessments and interventions
effectively.
6. Which assessment finding in a patient taking spironolactone indicates a potential adverse
effect?
A. Serum potassium of 5.8 mEq/L
B. Serum sodium of 135 mEq/L
C. Blood pressure of 110/70 mmHg
D. Increased urinary output
Answer: A
Rationale: Spironolactone is a potassium-sparing diuretic that works by antagonizing
aldosterone in the distal tubules. A serum potassium level of 5.8 mEq/L indicates
hyperkalemia, which is a significant risk for patients on this medication. Excessive
potassium retention can lead to cardiac arrest if not addressed through medication
adjustment or dietary restriction. The other options are either therapeutic effects or within
normal ranges. Educating patients to avoid potassium-rich salt substitutes is a critical
nursing responsibility.
7. A patient is receiving vancomycin IV for a MRSA infection. During the infusion, the patient
develops flushing of the neck and chest and reports itching. What should the nurse do first?
A. Stop the infusion immediately and notify the provider.
B. Slow the rate of the infusion.
C. Administer intramuscular epinephrine.
D. Apply a cold compress to the affected areas.
Answer: B
Rationale: The patient is describing Red Man Syndrome, a common infusion-related
reaction caused by the rapid administration of vancomycin. Unlike a true allergic reaction,
this is managed by slowing the infusion rate rather than stopping it entirely. The flushing
and pruritus are mediated by histamine release but usually do not progress to anaphylaxis
if the rate is corrected. Epinephrine is reserved for anaphylactic shock, which involves
airway compromise or hypotension. The nurse should continue to monitor the patient
closely for further changes in status.
