NUR280 Transition to RN Practice - EXAM 3
ULTIMATE 2026/2027 Review | Verified Q&A |
Galen College Nursing
Integrated Clinical Judgment & Complex Patient Management | Exam 3 Focus |
2026/2027 Standards
Galen College of Nursing | NUR 280 Transition to RN Practice | Exam 3 Review
PART 1 – EXAM 3 FOCUSED CONTENT SYNTHESIS (2026/2027)
Focus Theme: “The Complex Patient – When Bodies & Minds Decompensate Together”
Core Task for Exam 3: Synthesize medical-surgical acute care with active
behavioral-health comorbidities and lead the inter-professional response.
A. Managing the Patient with Multiple Chronic Conditions & Acute Decompensation
1. CHF + COPD + CKD + Depression (quadruple whammy)
• Acute trigger: pneumonia → ↑ sputum, ↑ RR, ↓ SpO₂, ↑ BP → flash pulmonary
edema → AKI → delirium
• 2026 Sequence:
– Hour 0: ABG, CXR, lactate, blood cultures, empiric abx (1-h sepsis bundle)
– Hour 1: BiPAP (IPAP 16/EPAP 6, FiO₂ 50 %), IV furosemide 2× home dose, KCl
40 mEq PO, check BNP, daily weight
– Hour 2: If pH <7.30 & PaCO₂ >65 → call RT for NIV adherence; if UOP <0.5
mL/kg/h → call CRRT early
• Depression impact: ↓ adherence, ↑ pain report → include mental-health consult,
restart SSRI by POD-1 if NPO <24 h (2026 APA peri-op guide)
, 2. Sepsis → ARDS → AKI → Delirium Cascade
• Lung-protective vent: Vt 6 mL/kg IBW, Pplat ≤30 cmH₂O, prone if PaO₂/FiO₂ <150
• Delirium prevention: CAM-ICU q8h, dexmedetomidine preferred over
benzodiazepines, early mobilization (sitting edge of bed POD-0 if MAP ≥65),
family photos at bedside, sleep bundle (lights off 2200-0500, no vitals unless
needed)
3. Diabetic Emergencies in the Med-Surg Patient with OUD
• DKA on floor: BG >300 mg/dL, pH <7.30, ketones → start insulin 0.1 units/kg/hr
even if on methadone 80 mg daily; continue methadone (abrupt stop →
withdrawal → ↑catecholamines → worsens acidosis)
• Pain control: continue buprenorphine 8 mg TID, add hydromorphone PCA
(higher opioid requirement), notify addiction medicine within 24 h
B. Integration of Mental Health Principles in the Medical-Surgical Setting
1. Delirium vs. Dementia vs. Depression vs. Depression-with-Delirium
• Delirium: acute, fluctuating, inattention (digit-span <5), CAM-ICU positive
• Dementia: chronic, stable baseline, normal attention
• Depression: mood ↓, sleep ↓, appetite ↓, but attention intact
• Management: treat underlying medical trigger first, then add low-dose
antipsychotic (haloperidol 0.5 mg PO BID) if distress/agitation; avoid
benzodiazepines unless alcohol withdrawal
2. Alcohol Withdrawal in the CHF Patient
• Start CIWA-Ar q4h; if score ≥10 → give lorazepam 2 mg IV q1h PRN, max 20
mg/24 h; add dexmedetomidine 0.2–0.7 mcg/kg/hr if needing >3 doses; monitor
for over-sedation → respiratory depression → hold digoxin if RR <10
3. Suicidal Ideation on a Med-Surg Floor
• Screen with Columbia CSSRS; if “I wish I were dead” = positive → 1:1 sitter,
remove all ligatures, call psychiatry within 1 h, document risk assessment q8h;
continue medical treatment; if patient refuses psych eval → inform charge →
provider → psychiatry attending → possible involuntary hold if high acute risk
C. Advanced Leadership & Delegation for Complex Assignment
Decision Tree 2026:
1. Unstable VS, titrating vasoactive or antiarrhythmic gtts, active bleeding, acute
mental status change → RN ONLY
, 2. Stable chronic wound care, Foley insertion, PO meds, VS on stable chronic
patients → LPN (under RN supervision)
3. Ambulation, hygiene, feeding, I/O, VS on stable patients → AP
4. Behavioral outburst: RN stays with patient, delegate stable patients to LPN/AP,
call security if safety risk, document factual objective statements only
PART 2 – INTEGRATED CLINICAL JUDGMENT PRACTICE EXAM
Complex Scenario Questions & Verified Solutions | Exam 3 Focus
Instructions: Time: 110 minutes. This exam focuses on integrated clinical judgment for
complex patients with dual physiological and psychosocial needs, per Exam 3 scope.
Apply the nursing process and 2026/2027 standards. Select the SINGLE BEST answer.
1. A 68-year-old male with CHF (EF 25 %, NYHA III), COPD Gold III, CKD stage 3b
(eGFR 35 mL/min), and major depressive disorder is admitted with pneumonia.
He recently lost his wife and lives alone. On arrival: BP 170/100, HR 118 irregular,
RR 32, SpO₂ 86 % on 4 L nasal cannula, temp 38.6 °C, crackles to scapula,
wheezes bilaterally, using accessory muscles. ABG: pH 7.28, PaCO₂ 68 mmHg,
PaO₂ 58 mmHg, HCO₃⁻ 30 mmol/L, lactate 3 mmol/L. CXR: bilateral infiltrates,
BNP 1,200 pg/mL (baseline 600), Cr 2.8 mg/dL (baseline 2.0), Na⁺ 132 mEq/L, K⁺
3.1 mEq/L, WBC 16 K with 85 % neutrophils. Current meds: furosemide 40 mg PO
daily, carvedilol 6.25 mg BID, sertraline 100 mg HS, methadone 60 mg daily for
chronic pain (OUD in remission 5 years). He is tearful and states, “I can’t breathe,
and I’m scared I’ll die like my wife.” Which intervention is priority?
A. Increase nasal cannula to 6 L/min and reassure in 10 min
B. Start BiPAP, IV furosemide 80 mg, and obtain blood cultures now*
C. Call psychiatry for acute grief counseling
D. Hold methadone until respiratory status improves
MASTERY RATIONALE:
Step 1 – Framework: Acute on chronic multi-system failure with anxiety; apply
NCJMM – Recognize Cues: hypoxemia + hypercapnia + fluid overload +
hypokalemia + infection.
Step 2 – Prioritize Hypotheses: ABC compromised → respiratory failure and
sepsis are life-threatening; grief is important but not immediate life threat.
Step 3 – Evidence: 2026 COPD/CHF guidelines: BiPAP for pH <7.35 & PaCO₂ >55
with hypoxia; double-dose IV loop diuretic for acute decompensation; sepsis
ULTIMATE 2026/2027 Review | Verified Q&A |
Galen College Nursing
Integrated Clinical Judgment & Complex Patient Management | Exam 3 Focus |
2026/2027 Standards
Galen College of Nursing | NUR 280 Transition to RN Practice | Exam 3 Review
PART 1 – EXAM 3 FOCUSED CONTENT SYNTHESIS (2026/2027)
Focus Theme: “The Complex Patient – When Bodies & Minds Decompensate Together”
Core Task for Exam 3: Synthesize medical-surgical acute care with active
behavioral-health comorbidities and lead the inter-professional response.
A. Managing the Patient with Multiple Chronic Conditions & Acute Decompensation
1. CHF + COPD + CKD + Depression (quadruple whammy)
• Acute trigger: pneumonia → ↑ sputum, ↑ RR, ↓ SpO₂, ↑ BP → flash pulmonary
edema → AKI → delirium
• 2026 Sequence:
– Hour 0: ABG, CXR, lactate, blood cultures, empiric abx (1-h sepsis bundle)
– Hour 1: BiPAP (IPAP 16/EPAP 6, FiO₂ 50 %), IV furosemide 2× home dose, KCl
40 mEq PO, check BNP, daily weight
– Hour 2: If pH <7.30 & PaCO₂ >65 → call RT for NIV adherence; if UOP <0.5
mL/kg/h → call CRRT early
• Depression impact: ↓ adherence, ↑ pain report → include mental-health consult,
restart SSRI by POD-1 if NPO <24 h (2026 APA peri-op guide)
, 2. Sepsis → ARDS → AKI → Delirium Cascade
• Lung-protective vent: Vt 6 mL/kg IBW, Pplat ≤30 cmH₂O, prone if PaO₂/FiO₂ <150
• Delirium prevention: CAM-ICU q8h, dexmedetomidine preferred over
benzodiazepines, early mobilization (sitting edge of bed POD-0 if MAP ≥65),
family photos at bedside, sleep bundle (lights off 2200-0500, no vitals unless
needed)
3. Diabetic Emergencies in the Med-Surg Patient with OUD
• DKA on floor: BG >300 mg/dL, pH <7.30, ketones → start insulin 0.1 units/kg/hr
even if on methadone 80 mg daily; continue methadone (abrupt stop →
withdrawal → ↑catecholamines → worsens acidosis)
• Pain control: continue buprenorphine 8 mg TID, add hydromorphone PCA
(higher opioid requirement), notify addiction medicine within 24 h
B. Integration of Mental Health Principles in the Medical-Surgical Setting
1. Delirium vs. Dementia vs. Depression vs. Depression-with-Delirium
• Delirium: acute, fluctuating, inattention (digit-span <5), CAM-ICU positive
• Dementia: chronic, stable baseline, normal attention
• Depression: mood ↓, sleep ↓, appetite ↓, but attention intact
• Management: treat underlying medical trigger first, then add low-dose
antipsychotic (haloperidol 0.5 mg PO BID) if distress/agitation; avoid
benzodiazepines unless alcohol withdrawal
2. Alcohol Withdrawal in the CHF Patient
• Start CIWA-Ar q4h; if score ≥10 → give lorazepam 2 mg IV q1h PRN, max 20
mg/24 h; add dexmedetomidine 0.2–0.7 mcg/kg/hr if needing >3 doses; monitor
for over-sedation → respiratory depression → hold digoxin if RR <10
3. Suicidal Ideation on a Med-Surg Floor
• Screen with Columbia CSSRS; if “I wish I were dead” = positive → 1:1 sitter,
remove all ligatures, call psychiatry within 1 h, document risk assessment q8h;
continue medical treatment; if patient refuses psych eval → inform charge →
provider → psychiatry attending → possible involuntary hold if high acute risk
C. Advanced Leadership & Delegation for Complex Assignment
Decision Tree 2026:
1. Unstable VS, titrating vasoactive or antiarrhythmic gtts, active bleeding, acute
mental status change → RN ONLY
, 2. Stable chronic wound care, Foley insertion, PO meds, VS on stable chronic
patients → LPN (under RN supervision)
3. Ambulation, hygiene, feeding, I/O, VS on stable patients → AP
4. Behavioral outburst: RN stays with patient, delegate stable patients to LPN/AP,
call security if safety risk, document factual objective statements only
PART 2 – INTEGRATED CLINICAL JUDGMENT PRACTICE EXAM
Complex Scenario Questions & Verified Solutions | Exam 3 Focus
Instructions: Time: 110 minutes. This exam focuses on integrated clinical judgment for
complex patients with dual physiological and psychosocial needs, per Exam 3 scope.
Apply the nursing process and 2026/2027 standards. Select the SINGLE BEST answer.
1. A 68-year-old male with CHF (EF 25 %, NYHA III), COPD Gold III, CKD stage 3b
(eGFR 35 mL/min), and major depressive disorder is admitted with pneumonia.
He recently lost his wife and lives alone. On arrival: BP 170/100, HR 118 irregular,
RR 32, SpO₂ 86 % on 4 L nasal cannula, temp 38.6 °C, crackles to scapula,
wheezes bilaterally, using accessory muscles. ABG: pH 7.28, PaCO₂ 68 mmHg,
PaO₂ 58 mmHg, HCO₃⁻ 30 mmol/L, lactate 3 mmol/L. CXR: bilateral infiltrates,
BNP 1,200 pg/mL (baseline 600), Cr 2.8 mg/dL (baseline 2.0), Na⁺ 132 mEq/L, K⁺
3.1 mEq/L, WBC 16 K with 85 % neutrophils. Current meds: furosemide 40 mg PO
daily, carvedilol 6.25 mg BID, sertraline 100 mg HS, methadone 60 mg daily for
chronic pain (OUD in remission 5 years). He is tearful and states, “I can’t breathe,
and I’m scared I’ll die like my wife.” Which intervention is priority?
A. Increase nasal cannula to 6 L/min and reassure in 10 min
B. Start BiPAP, IV furosemide 80 mg, and obtain blood cultures now*
C. Call psychiatry for acute grief counseling
D. Hold methadone until respiratory status improves
MASTERY RATIONALE:
Step 1 – Framework: Acute on chronic multi-system failure with anxiety; apply
NCJMM – Recognize Cues: hypoxemia + hypercapnia + fluid overload +
hypokalemia + infection.
Step 2 – Prioritize Hypotheses: ABC compromised → respiratory failure and
sepsis are life-threatening; grief is important but not immediate life threat.
Step 3 – Evidence: 2026 COPD/CHF guidelines: BiPAP for pH <7.35 & PaCO₂ >55
with hypoxia; double-dose IV loop diuretic for acute decompensation; sepsis
