1
NURS 5433 Final ACTUAL EXAM
2026/2027 | All Questions and Correct
Verified Answers | Pass Guaranteed -
A+ Graded
Question 1
A 68-year-old patient with metastatic melanoma, type 2 diabetes, and recent COVID-19 infection
presents with progressive dyspnea, hypoxemia requiring 15L high-flow nasal cannula, and
diffuse ground-glass opacities on CT. The oncology team is considering pembrolizumab restart.
Which pathophysiological mechanism best explains the likely cause of respiratory failure, and
what is the most critical diagnostic test to guide immediate therapy?
A. Checkpoint inhibitor-induced pneumonitis; serum IL-6 level and corticosteroid trial
B. COVID-19-related pulmonary fibrosis; bronchoalveolar lavage for viral cultures
C. Drug-induced organizing pneumonia; transbronchial biopsy for definitive diagnosis
D. Immune-related adverse event (irAE) vs. viral pneumonia; CRP, procalcitonin, and BAL with
viral PCR panel
Correct Answer: D
Detailed Rationale: This complex presentation demonstrates the critical differential between
immune-related adverse events (irAEs) and persistent viral pathology in the
immunocompromised host. The 2026 ASCO guidelines emphasize that checkpoint inhibitor-
related pneumonitis occurs in 3-5% of patients, typically 2-24 months after initiation, but can be
precipitated by viral triggers. The concurrent temporal relationship with recent COVID-19,
which can cause persistent viral shedding and immune dysregulation, necessitates a multimodal
diagnostic approach. While corticosteroids are first-line for irAEs, premature administration
without excluding active viral replication risks worsening infection. The serum IL-6 elevation
(Option A) is non-specific and appears in both conditions. Transbronchial biopsy (Option C)
carries prohibitive risk in a hypoxemic patient. The evidence-based approach requires both
inflammatory markers (CRP, procalcitonin) and BAL with multiplex PCR to differentiate viral
persistence from irAEs before initiating immunosuppression. This reflects the 2026 shift toward
precision diagnostics in onco-immunology.
,2
Question 2
A rural critical access hospital's leadership team is implementing an AI-driven predictive
analytics platform for sepsis detection. Which ethical framework best addresses the tension
between improved outcomes and algorithmic bias against underrepresented populations in the
training data, and what concurrent quality measure should be prioritized?
A. Utilitarianism; implement algorithm immediately, measuring aggregate mortality reduction
B. Justice and health equity; conduct algorithmic fairness auditing with demographic
stratification of sensitivity/specificity before deployment, addressing model drift
C. Deontology; reject AI implementation as it violates individual physician autonomy in
diagnosis
D. Virtue ethics; deploy system while training staff on compassionate care to offset bias
Correct Answer: B
Detailed Rationale: The 2026 WHO guidance on AI in healthcare explicitly requires algorithmic
fairness assessment as a quality imperative, not an afterthought. Historical sepsis algorithms have
demonstrated 15-20% lower sensitivity in Black and Hispanic populations due to biased vital
sign baselines and lab thresholds. A justice-based framework demands proactive demographic
stratification of performance metrics, continuous monitoring for model drift, and transparent
reporting to CMS quality programs. Option A's utilitarian approach ignores distributive justice
and violates the Joint Commission's 2026 health equity standards. Option C's categorical
rejection ignores AI's proven mortality benefits (NNT ≈ 50 for sepsis bundle activation). Option
D's virtue-based approach is insufficient without structural bias mitigation.
Question 3
A 72-year-old patient with heart failure with preserved ejection fraction (HFpEF), CKD stage 3b
(eGFR 32 mL/min), and atrial fibrillation on apixaban presents with acute decompensated HF.
The admitting team must balance diuresis with renal perfusion while managing anticoagulation.
Based on 2026 ACC/AHA/HFSA HF guidelines, which medication adjustment represents the
most evidence-based approach?
A. Initiate high-dose loop diuretic bolus, continue apixaban at standard dose, add empagliflozin
10 mg daily
B. Start continuous loop diuretic infusion, reduce apixaban dose by 50% due to CKD, hold
SGLT2 inhibitor until eGFR >45
C. Use loop diuretic with metolazone synergy, continue apixaban with anti-Xa monitoring,
empagliflozin 10 mg regardless of eGFR down to 20
,3
D. Replace apixaban with warfarin for better renal clearance monitoring, avoid diuretics in
HFpEF
Correct Answer: C
Detailed Rationale: The 2026 HF guideline update fundamentally changed SGLT2 inhibitor
recommendations, now endorsing empagliflozin for HFpEF down to eGFR 20 mL/min based on
EMPEROR-Preserved extended follow-up showing preserved cardiovascular benefit. For
diuretic resistance in CKD, the metolazone-loop synergy achieves effective natriuresis. While
apixaban dose reduction is recommended for severe CKD (eGFR 15-29) or end-stage disease, in
stage 3b with AF, the standard DOAC dose maintains stroke prevention with lower bleeding risk
than warfarin. Anti-Xa monitoring (though not required by FDA) provides pharmacokinetic
precision in this high-risk scenario. Option A's standard-dose diuretic is insufficient for high loop
threshold in CKD. Option B's SGLT2 hold contradicts current evidence. Option D's warfarin
substitution increases bleeding and monitoring burden without benefit.
Question 4
A hospital system is transitioning to a value-based care model for total joint arthroplasty. The
leadership must redesign care pathways, incentive structures, and quality metrics. Which
organizational change theory best predicts resistance from orthopedic surgeons, and which
countermeasure is most effective?
A. Lewin's Unfreeze-Change-Refreeze; mandating participation with financial penalties for non-
compliance
B. Kotter's 8-Step Model; building urgency through data on cost variation while creating a
guiding coalition that includes respected surgeon champions
C. Roger's Diffusion of Innovations; focusing on early adopters and ignoring late
majority/laggards
D. Complexity Science; allowing self-organization without structured intervention
Correct Answer: B
Detailed Rationale: Kotter's framework systematically addresses physician resistance by
targeting both rational and emotional drivers. The 2026 CMS Bundled Payments for Care
Improvement Advanced (BPCI-A) program requires surgeon engagement in episode-based cost
accountability. Step 1 (Create Urgency) leverages surgeons' competitive nature through peer-
comparison dashboards of cost and outcomes. Step 2 (Guiding Coalition) is critical—surgeon
champions provide peer credibility that administrative mandates lack. Lewin's model (Option A)
is too simplistic for complex professional culture change and mandates generate covert
resistance. Roger's model (Option C) insufficiently addresses the power dynamics in physician-
, 4
led departments. Complexity science (Option D) underestimates the need for deliberate structure
in high-stakes reimbursement models.
Question 5
A patient with BRCA1-positive triple-negative breast cancer is considering neoadjuvant
immunotherapy (pembrolizumab + chemotherapy). Pharmacogenomic testing reveals a CYP2D6
poor metabolizer phenotype. The oncology nurse navigator must coordinate care with pharmacy,
genetics, and psychosocial services. Which factor represents the most critical safety
consideration for this treatment plan?
A. Increased risk of immune-related adverse events due to CYP2D6 status requiring proactive
steroid prescription
B. Potential for severe psychiatric adverse events from pembrolizumab, amplified by inability to
metabolize certain psychotropic medications used for anxiety management
C. No safety implications; CYP2D6 metabolism doesn't affect immune checkpoint inhibitors
D. Chemotherapy dose reduction is mandatory for poor metabolizers regardless of regimen
Correct Answer: B
Detailed Rationale: This scenario illustrates pharmacogenomic polypharmacy interactions in
complex regimens. While pembrolizumab itself is not metabolized by CYP2D6, cancer treatment
induces psychological distress requiring medications (SSRIs, trazodone for sleep) that are
CYP2D6 substrates. The 2026 ASCO pharmacogenomics guideline highlights that poor
metabolizers have 3-5x higher active drug levels, increasing toxicity risk. Specifically, SSRIs
metabolized by CYP2D6 (fluoxetine, paroxetine, some TCAs) can accumulate, causing serotonin
syndrome or worsening immune-related neurotoxicity. Additionally, if the patient requires
steroids for irAEs, CYP3A4 interactions must be considered. Option A incorrectly links CYP2D6
to immune efficacy. Option C ignores the indirect pharmacogenomic impact on supportive care.
Option D overgeneralizes—dose adjustments depend on specific chemo agents (e.g., tamoxifen
is affected, but taxanes/platinum in TNBC regimen are not CYP2D6 dependent).
Question 6
A Magnet-designated hospital's Chief Nursing Officer is implementing clinical ladder
advancement for nurse practitioners that links promotion to participation in QI projects and
publication. Which regulatory framework must guide this program to ensure compliance with
2026 HR standards and avoid wage discrimination claims?
A. Fair Labor Standards Act (FLSA) exempt status rules for professionals
B. Title VII of the Civil Rights Act with pay equity analysis across protected classes
C. National Labor Relations Act provisions for collective bargaining units
NURS 5433 Final ACTUAL EXAM
2026/2027 | All Questions and Correct
Verified Answers | Pass Guaranteed -
A+ Graded
Question 1
A 68-year-old patient with metastatic melanoma, type 2 diabetes, and recent COVID-19 infection
presents with progressive dyspnea, hypoxemia requiring 15L high-flow nasal cannula, and
diffuse ground-glass opacities on CT. The oncology team is considering pembrolizumab restart.
Which pathophysiological mechanism best explains the likely cause of respiratory failure, and
what is the most critical diagnostic test to guide immediate therapy?
A. Checkpoint inhibitor-induced pneumonitis; serum IL-6 level and corticosteroid trial
B. COVID-19-related pulmonary fibrosis; bronchoalveolar lavage for viral cultures
C. Drug-induced organizing pneumonia; transbronchial biopsy for definitive diagnosis
D. Immune-related adverse event (irAE) vs. viral pneumonia; CRP, procalcitonin, and BAL with
viral PCR panel
Correct Answer: D
Detailed Rationale: This complex presentation demonstrates the critical differential between
immune-related adverse events (irAEs) and persistent viral pathology in the
immunocompromised host. The 2026 ASCO guidelines emphasize that checkpoint inhibitor-
related pneumonitis occurs in 3-5% of patients, typically 2-24 months after initiation, but can be
precipitated by viral triggers. The concurrent temporal relationship with recent COVID-19,
which can cause persistent viral shedding and immune dysregulation, necessitates a multimodal
diagnostic approach. While corticosteroids are first-line for irAEs, premature administration
without excluding active viral replication risks worsening infection. The serum IL-6 elevation
(Option A) is non-specific and appears in both conditions. Transbronchial biopsy (Option C)
carries prohibitive risk in a hypoxemic patient. The evidence-based approach requires both
inflammatory markers (CRP, procalcitonin) and BAL with multiplex PCR to differentiate viral
persistence from irAEs before initiating immunosuppression. This reflects the 2026 shift toward
precision diagnostics in onco-immunology.
,2
Question 2
A rural critical access hospital's leadership team is implementing an AI-driven predictive
analytics platform for sepsis detection. Which ethical framework best addresses the tension
between improved outcomes and algorithmic bias against underrepresented populations in the
training data, and what concurrent quality measure should be prioritized?
A. Utilitarianism; implement algorithm immediately, measuring aggregate mortality reduction
B. Justice and health equity; conduct algorithmic fairness auditing with demographic
stratification of sensitivity/specificity before deployment, addressing model drift
C. Deontology; reject AI implementation as it violates individual physician autonomy in
diagnosis
D. Virtue ethics; deploy system while training staff on compassionate care to offset bias
Correct Answer: B
Detailed Rationale: The 2026 WHO guidance on AI in healthcare explicitly requires algorithmic
fairness assessment as a quality imperative, not an afterthought. Historical sepsis algorithms have
demonstrated 15-20% lower sensitivity in Black and Hispanic populations due to biased vital
sign baselines and lab thresholds. A justice-based framework demands proactive demographic
stratification of performance metrics, continuous monitoring for model drift, and transparent
reporting to CMS quality programs. Option A's utilitarian approach ignores distributive justice
and violates the Joint Commission's 2026 health equity standards. Option C's categorical
rejection ignores AI's proven mortality benefits (NNT ≈ 50 for sepsis bundle activation). Option
D's virtue-based approach is insufficient without structural bias mitigation.
Question 3
A 72-year-old patient with heart failure with preserved ejection fraction (HFpEF), CKD stage 3b
(eGFR 32 mL/min), and atrial fibrillation on apixaban presents with acute decompensated HF.
The admitting team must balance diuresis with renal perfusion while managing anticoagulation.
Based on 2026 ACC/AHA/HFSA HF guidelines, which medication adjustment represents the
most evidence-based approach?
A. Initiate high-dose loop diuretic bolus, continue apixaban at standard dose, add empagliflozin
10 mg daily
B. Start continuous loop diuretic infusion, reduce apixaban dose by 50% due to CKD, hold
SGLT2 inhibitor until eGFR >45
C. Use loop diuretic with metolazone synergy, continue apixaban with anti-Xa monitoring,
empagliflozin 10 mg regardless of eGFR down to 20
,3
D. Replace apixaban with warfarin for better renal clearance monitoring, avoid diuretics in
HFpEF
Correct Answer: C
Detailed Rationale: The 2026 HF guideline update fundamentally changed SGLT2 inhibitor
recommendations, now endorsing empagliflozin for HFpEF down to eGFR 20 mL/min based on
EMPEROR-Preserved extended follow-up showing preserved cardiovascular benefit. For
diuretic resistance in CKD, the metolazone-loop synergy achieves effective natriuresis. While
apixaban dose reduction is recommended for severe CKD (eGFR 15-29) or end-stage disease, in
stage 3b with AF, the standard DOAC dose maintains stroke prevention with lower bleeding risk
than warfarin. Anti-Xa monitoring (though not required by FDA) provides pharmacokinetic
precision in this high-risk scenario. Option A's standard-dose diuretic is insufficient for high loop
threshold in CKD. Option B's SGLT2 hold contradicts current evidence. Option D's warfarin
substitution increases bleeding and monitoring burden without benefit.
Question 4
A hospital system is transitioning to a value-based care model for total joint arthroplasty. The
leadership must redesign care pathways, incentive structures, and quality metrics. Which
organizational change theory best predicts resistance from orthopedic surgeons, and which
countermeasure is most effective?
A. Lewin's Unfreeze-Change-Refreeze; mandating participation with financial penalties for non-
compliance
B. Kotter's 8-Step Model; building urgency through data on cost variation while creating a
guiding coalition that includes respected surgeon champions
C. Roger's Diffusion of Innovations; focusing on early adopters and ignoring late
majority/laggards
D. Complexity Science; allowing self-organization without structured intervention
Correct Answer: B
Detailed Rationale: Kotter's framework systematically addresses physician resistance by
targeting both rational and emotional drivers. The 2026 CMS Bundled Payments for Care
Improvement Advanced (BPCI-A) program requires surgeon engagement in episode-based cost
accountability. Step 1 (Create Urgency) leverages surgeons' competitive nature through peer-
comparison dashboards of cost and outcomes. Step 2 (Guiding Coalition) is critical—surgeon
champions provide peer credibility that administrative mandates lack. Lewin's model (Option A)
is too simplistic for complex professional culture change and mandates generate covert
resistance. Roger's model (Option C) insufficiently addresses the power dynamics in physician-
, 4
led departments. Complexity science (Option D) underestimates the need for deliberate structure
in high-stakes reimbursement models.
Question 5
A patient with BRCA1-positive triple-negative breast cancer is considering neoadjuvant
immunotherapy (pembrolizumab + chemotherapy). Pharmacogenomic testing reveals a CYP2D6
poor metabolizer phenotype. The oncology nurse navigator must coordinate care with pharmacy,
genetics, and psychosocial services. Which factor represents the most critical safety
consideration for this treatment plan?
A. Increased risk of immune-related adverse events due to CYP2D6 status requiring proactive
steroid prescription
B. Potential for severe psychiatric adverse events from pembrolizumab, amplified by inability to
metabolize certain psychotropic medications used for anxiety management
C. No safety implications; CYP2D6 metabolism doesn't affect immune checkpoint inhibitors
D. Chemotherapy dose reduction is mandatory for poor metabolizers regardless of regimen
Correct Answer: B
Detailed Rationale: This scenario illustrates pharmacogenomic polypharmacy interactions in
complex regimens. While pembrolizumab itself is not metabolized by CYP2D6, cancer treatment
induces psychological distress requiring medications (SSRIs, trazodone for sleep) that are
CYP2D6 substrates. The 2026 ASCO pharmacogenomics guideline highlights that poor
metabolizers have 3-5x higher active drug levels, increasing toxicity risk. Specifically, SSRIs
metabolized by CYP2D6 (fluoxetine, paroxetine, some TCAs) can accumulate, causing serotonin
syndrome or worsening immune-related neurotoxicity. Additionally, if the patient requires
steroids for irAEs, CYP3A4 interactions must be considered. Option A incorrectly links CYP2D6
to immune efficacy. Option C ignores the indirect pharmacogenomic impact on supportive care.
Option D overgeneralizes—dose adjustments depend on specific chemo agents (e.g., tamoxifen
is affected, but taxanes/platinum in TNBC regimen are not CYP2D6 dependent).
Question 6
A Magnet-designated hospital's Chief Nursing Officer is implementing clinical ladder
advancement for nurse practitioners that links promotion to participation in QI projects and
publication. Which regulatory framework must guide this program to ensure compliance with
2026 HR standards and avoid wage discrimination claims?
A. Fair Labor Standards Act (FLSA) exempt status rules for professionals
B. Title VII of the Civil Rights Act with pay equity analysis across protected classes
C. National Labor Relations Act provisions for collective bargaining units
