NUR 265 Exam 2 | Advanced Concepts of Medical-Surgical
Nursing (2026) Q&A | Galen College
1. A client with heart failure has a potassium level of 3.0 mEq/L after receiving furosemide.
What is the priority nursing action?
A) Administer the next scheduled dose of furosemide
B) Hold the furosemide and notify the provider
C) Encourage potassium-rich foods only
D) Document the finding and continue monitoring
Correct Answer: B) Hold the furosemide and notify the provider
Rationale: Furosemide is a loop diuretic that causes potassium wasting. Administering it to a
patient with hypokalemia (K+ 3.0 mEq/L) increases the risk of life-threatening cardiac
dysrhythmias. The nurse should hold the dose and notify the provider for further orders .
2. A patient with an inferior wall myocardial infarction is prescribed nitroglycerin. Which
assessment finding requires withholding the medication?
A) Heart rate of 88 bpm
B) Blood pressure of 86/54 mmHg
C) Respiratory rate of 20 breaths/min
D) Pain level of 6/10
Correct Answer: B) Blood pressure of 86/54 mmHg
,Rationale: Nitroglycerin is a vasodilator that can cause severe hypotension. It should be
withheld if the systolic blood pressure is less than 90 mmHg. Inferior wall MIs are particularly
sensitive to preload reduction, and nitroglycerin should be used cautiously .
3. A nurse is assessing a patient with left-sided heart failure. Which finding is most consistent
with this condition?
A) Jugular venous distention and peripheral edema
B) Crackles in the lung bases and orthopnea
C) Hepatomegaly and ascites
D) Weight gain and dependent edema
Correct Answer: B) Crackles in the lung bases and orthopnea
Rationale: Left-sided heart failure causes pulmonary congestion, leading to crackles, dyspnea,
orthopnea, and paroxysmal nocturnal dyspnea. Right-sided heart failure presents with systemic
congestion such as jugular venous distention, peripheral edema, hepatomegaly, and ascites .
4. A patient with atrial fibrillation has a heart rate of 138 bpm and is symptomatic. Which
medication should the nurse anticipate administering for rate control?
A) Adenosine
B) Diltiazem
C) Atropine
D) Epinephrine
Correct Answer: B) Diltiazem
,Rationale: Diltiazem is a calcium channel blocker used for rate control in atrial fibrillation by
slowing AV nodal conduction. Adenosine is used for supraventricular tachycardia. Atropine is
used for bradycardia. Epinephrine is used for cardiac arrest .
5. A nurse is teaching a patient about warfarin therapy. Which statement indicates a need for
further teaching?
A) "I will avoid foods high in vitamin K."
B) "I will keep my appointments for blood tests."
C) "I will increase my intake of leafy green vegetables."
D) "I will report any unusual bleeding."
Correct Answer: C) "I will increase my intake of leafy green vegetables."
Rationale: Warfarin works by inhibiting vitamin K-dependent clotting factors. Increasing intake
of leafy green vegetables (high in vitamin K) can decrease the INR and increase clotting risk.
Patients should maintain consistent intake of vitamin K .
6. Which finding is most concerning in a patient receiving a blood transfusion?
A) Temperature of 100.2°F
B) Heart rate of 90 bpm
C) Blood pressure of 120/80 mmHg
D) Mild erythema at the IV site
Correct Answer: A) Temperature of 100.2°F
, Rationale: Fever during a blood transfusion may indicate a hemolytic transfusion reaction or
bacterial contamination. The nurse should stop the transfusion immediately, maintain IV access
with normal saline, and notify the provider .
7. A patient with a pulmonary embolism is started on a heparin infusion. Which laboratory value
should the nurse monitor to evaluate therapeutic effectiveness?
A) PT/INR
B) aPTT
C) Platelet count
D) Hemoglobin
Correct Answer: B) aPTT
Rationale: Heparin therapy is monitored using the activated partial thromboplastin time (aPTT).
The therapeutic goal is typically 1.5-2.5 times the control value. PT/INR is used to monitor
warfarin therapy .
8. A patient with a deep vein thrombosis is receiving a continuous heparin infusion. The nurse
notes the aPTT is 95 seconds (therapeutic range: 60-80 seconds). What is the priority nursing
action?
A) Stop the heparin infusion immediately
B) Continue the infusion at the current rate
C) Increase the heparin infusion rate
D) Administer vitamin K
Correct Answer: A) Stop the heparin infusion immediately
Nursing (2026) Q&A | Galen College
1. A client with heart failure has a potassium level of 3.0 mEq/L after receiving furosemide.
What is the priority nursing action?
A) Administer the next scheduled dose of furosemide
B) Hold the furosemide and notify the provider
C) Encourage potassium-rich foods only
D) Document the finding and continue monitoring
Correct Answer: B) Hold the furosemide and notify the provider
Rationale: Furosemide is a loop diuretic that causes potassium wasting. Administering it to a
patient with hypokalemia (K+ 3.0 mEq/L) increases the risk of life-threatening cardiac
dysrhythmias. The nurse should hold the dose and notify the provider for further orders .
2. A patient with an inferior wall myocardial infarction is prescribed nitroglycerin. Which
assessment finding requires withholding the medication?
A) Heart rate of 88 bpm
B) Blood pressure of 86/54 mmHg
C) Respiratory rate of 20 breaths/min
D) Pain level of 6/10
Correct Answer: B) Blood pressure of 86/54 mmHg
,Rationale: Nitroglycerin is a vasodilator that can cause severe hypotension. It should be
withheld if the systolic blood pressure is less than 90 mmHg. Inferior wall MIs are particularly
sensitive to preload reduction, and nitroglycerin should be used cautiously .
3. A nurse is assessing a patient with left-sided heart failure. Which finding is most consistent
with this condition?
A) Jugular venous distention and peripheral edema
B) Crackles in the lung bases and orthopnea
C) Hepatomegaly and ascites
D) Weight gain and dependent edema
Correct Answer: B) Crackles in the lung bases and orthopnea
Rationale: Left-sided heart failure causes pulmonary congestion, leading to crackles, dyspnea,
orthopnea, and paroxysmal nocturnal dyspnea. Right-sided heart failure presents with systemic
congestion such as jugular venous distention, peripheral edema, hepatomegaly, and ascites .
4. A patient with atrial fibrillation has a heart rate of 138 bpm and is symptomatic. Which
medication should the nurse anticipate administering for rate control?
A) Adenosine
B) Diltiazem
C) Atropine
D) Epinephrine
Correct Answer: B) Diltiazem
,Rationale: Diltiazem is a calcium channel blocker used for rate control in atrial fibrillation by
slowing AV nodal conduction. Adenosine is used for supraventricular tachycardia. Atropine is
used for bradycardia. Epinephrine is used for cardiac arrest .
5. A nurse is teaching a patient about warfarin therapy. Which statement indicates a need for
further teaching?
A) "I will avoid foods high in vitamin K."
B) "I will keep my appointments for blood tests."
C) "I will increase my intake of leafy green vegetables."
D) "I will report any unusual bleeding."
Correct Answer: C) "I will increase my intake of leafy green vegetables."
Rationale: Warfarin works by inhibiting vitamin K-dependent clotting factors. Increasing intake
of leafy green vegetables (high in vitamin K) can decrease the INR and increase clotting risk.
Patients should maintain consistent intake of vitamin K .
6. Which finding is most concerning in a patient receiving a blood transfusion?
A) Temperature of 100.2°F
B) Heart rate of 90 bpm
C) Blood pressure of 120/80 mmHg
D) Mild erythema at the IV site
Correct Answer: A) Temperature of 100.2°F
, Rationale: Fever during a blood transfusion may indicate a hemolytic transfusion reaction or
bacterial contamination. The nurse should stop the transfusion immediately, maintain IV access
with normal saline, and notify the provider .
7. A patient with a pulmonary embolism is started on a heparin infusion. Which laboratory value
should the nurse monitor to evaluate therapeutic effectiveness?
A) PT/INR
B) aPTT
C) Platelet count
D) Hemoglobin
Correct Answer: B) aPTT
Rationale: Heparin therapy is monitored using the activated partial thromboplastin time (aPTT).
The therapeutic goal is typically 1.5-2.5 times the control value. PT/INR is used to monitor
warfarin therapy .
8. A patient with a deep vein thrombosis is receiving a continuous heparin infusion. The nurse
notes the aPTT is 95 seconds (therapeutic range: 60-80 seconds). What is the priority nursing
action?
A) Stop the heparin infusion immediately
B) Continue the infusion at the current rate
C) Increase the heparin infusion rate
D) Administer vitamin K
Correct Answer: A) Stop the heparin infusion immediately
