Galen College of Nursing
NSG 4100
Exam 2
Review
2026/2027
Adult
Comprehensive Critical Care Study Guide - 50 Questions
Course: NSG 4100 Adult Health III
Program: Bachelor of Science in Nursing (BSN)
Exam Cycle: 2026/2027 Academic Year
Content: 100% Correct Verified Solutions -
Grade A
Galen College of Nursing
,Section 1: Complex Cardiovascular Disorders
1. A patient with acute decompensated heart failure (ADHF) presents with dyspnea at rest, bilateral
crackles, jugular venous distension (JVD), and 3+ pitting edema. Blood pressure is 85/50 mmHg,
heart rate 110 bpm. Which hemodynamic profile per the Nohria-Stevenson classification does this
patient represent?
A. Profile A (warm and dry)
B. Profile B (warm and wet)
C. Profile L (cold and dry)
D. Profile C (cold and wet)
Rationale: Profile C (cold and wet) represents the most hemodynamically compromised
ADHF presentation: inadequate perfusion (cold: low cardiac output evidenced by
hypotension, cool extremities, end-organ hypoperfusion) with congestion (wet: elevated
filling pressures evidenced by JVD, crackles, edema). The Nohria-Stevenson classification
guides therapy: Profile C patients require inotropic support (dobutamine or milrinone) plus
vasodilators or vasopressors depending on blood pressure, and often mechanical circulatory
support. Profile A (warm/dry) is compensated and stable. Profile B (warm/wet) needs
diuresis with vasodilators. Profile L (cold/dry) needs cautious volume expansion and
inotropes.
2. A patient with a left ventricular assist device (LVAD) reports feeling fatigued and noticing the
device's flow rate has decreased from 5.0 to 2.8 L/min. The pump power has also decreased. The
driveline site appears intact. What is the most likely cause?
A. LVAD infection
B. Pump thrombosis
C. Right ventricular failure
D. Driveline fracture
Rationale: Decreased pump flow and power with fatigue are classic signs of LVAD pump
thrombosis. Other indicators include elevated LDH, hemolysis (plasma-free hemoglobin),
and pump alarm events. Confirmation requires echocardiography (evaluating the aortic
valve opening pattern and LV unloading) and CT angiography. Management ranges from
anticoagulation intensification (heparin drip) to thrombolytic therapy or surgical pump
exchange for refractory cases. Driveline fracture would cause a pump stop alarm, not
gradual flow decrease. RV failure would present with systemic congestion (JVD,
hepatomegaly) but not primarily decreased pump parameters. LVAD infection typically
presents with driveline site erythema, drainage, and fever.
3. A patient arrives to the ED with STEMI. Door-to-balloon time is achieved in 62 minutes. Post-
PCI, which medication regimen is initiated per current AHA/ACC guidelines?
A. Aspirin 81 mg daily only
B. Dual antiplatelet therapy (DAPT) with aspirin plus a P2Y12 inhibitor, high-
intensity statin, beta-blocker, and ACE inhibitor
C. Warfarin with INR monitoring
D. Clopidogrel monotherapy
Rationale: Post-PCI guideline-directed medical therapy (GDMT) includes: DAPT (aspirin
81 mg plus P2Y12 inhibitor: clopidogrel, prasugrel, or ticagrelor) for 6-12 months depending
on bleeding risk and stent type; high-intensity statin (atorvastatin 40-80 mg); beta-blocker
(metoprolol succinate or carvedilol) within 24 hours; and ACE inhibitor or ARB (especially
if EF less than 40%, HTN, diabetes, or CKD). The AHA/ACC 2023 guidelines emphasize
early initiation. Door-to-balloon time target is less than 90 minutes; this patient achieved 62
minutes, which is optimal.
4. A patient with severe aortic stenosis (aortic valve area 0.6 cm2, mean gradient 48 mmHg)
presents with syncope, exertional angina, and dyspnea. Ejection fraction is 55%. What is the
definitive treatment?
A. Medical management with diuretics only
1
, B. Surgical aortic valve replacement (SAVR) or transcatheter aortic valve
replacement (TAVR)
C. Aortic balloon valvuloplasty
D. Antibiotic prophylaxis and observation
Rationale: This patient has severe aortic stenosis with classic triad symptoms (syncope,
angina, dyspnea), indicating poor prognosis with medical management alone (average
survival less than 2-3 years with syncope). The 2020 ACC/AHA Valvular Heart Disease
guidelines recommend aortic valve replacement (SAVR or TAVR) as Class I indication for
symptomatic severe AS regardless of EF. TAVR is preferred for patients greater than 75 or
those with high surgical risk (STS score greater than 8%). SAVR remains preferred for
younger patients (less than 65) and those with concomitant coronary artery disease
requiring CABG. Balloon valvuloplasty is a bridge therapy only, not definitive.
Section 2: Cardiac Dysrhythmias and Cardiogenic Shock
5. A patient with atrial fibrillation with rapid ventricular response (HR 152 bpm) is
hemodynamically unstable (BP 78/50, altered mental status, diaphoresis). What is the immediate
nursing action?
A. Administer metoprolol IV
B. Prepare for immediate synchronized cardioversion
C. Administer amiodarone IV drip
D. Apply vagal maneuvers
Rationale: Hemodynamically unstable AFib with RVR (hypotension, altered mental status,
chest pain, acute heart failure) requires immediate synchronized cardioversion per ACLS
guidelines. Synchronized cardioversion delivers a shock timed to the QRS complex to avoid
shocking during the vulnerable repolarization period (T wave), which could precipitate
ventricular fibrillation. Initial energy: 120-200J biphasic. If the patient is stable, rate
control (diltiazem, metoprolol, or amiodarone) or rhythm control strategies are
appropriate. Vagal maneuvers are for stable SVT. Metoprolol would worsen hypotension in
this patient and is contraindicated in hemodynamically unstable patients.
6. A patient in cardiogenic shock has the following hemodynamic parameters: BP 82/50, HR 118,
CVP 18 mmHg, cardiac output 3.2 L/min, SVR 1600 dynes/sec/cm5, PAOP/PCWP 28 mmHg.
Which medication should the nurse anticipate administering?
A. Nitroprusside
B. Norepinephrine
C. Dobutamine
D. Phenylephrine
Rationale: This patient has cardiogenic shock: low cardiac output (3.2 L/min; normal 4-
8), elevated filling pressures (CVP 18, PAOP 28), and adequate-to-elevated SVR (1600). The
primary problem is pump failure, not vasodilation. Dobutamine (a beta-1 agonist inotrope)
is the first-line inotrope for cardiogenic shock to improve cardiac output and myocardial
contractility while causing mild vasodilation. However, if hypotension is severe (MAP less
than 65), norepinephrine is added to maintain coronary perfusion pressure. Nitroprusside
(vasodilator) would worsen hypotension. Phenylephrine (pure alpha agonist) increases
afterload and would further impair cardiac output.
7. A patient with a permanent pacemaker develops hiccups and intermittent pectoral muscle
twitching. What complication does this most likely indicate?
A. Lead fracture
B. Phrenic nerve stimulation from atrial lead placement
C. Pacemaker-mediated tachycardia
D. Endocarditis
Rationale: Unilateral diaphragmatic (phrenic nerve) stimulation and pectoral muscle
twitching indicate that the pacemaker lead is positioned too close to the phrenic nerve or is
delivering excessive output. The phrenic nerve innervates the diaphragm and runs along the
2
NSG 4100
Exam 2
Review
2026/2027
Adult
Comprehensive Critical Care Study Guide - 50 Questions
Course: NSG 4100 Adult Health III
Program: Bachelor of Science in Nursing (BSN)
Exam Cycle: 2026/2027 Academic Year
Content: 100% Correct Verified Solutions -
Grade A
Galen College of Nursing
,Section 1: Complex Cardiovascular Disorders
1. A patient with acute decompensated heart failure (ADHF) presents with dyspnea at rest, bilateral
crackles, jugular venous distension (JVD), and 3+ pitting edema. Blood pressure is 85/50 mmHg,
heart rate 110 bpm. Which hemodynamic profile per the Nohria-Stevenson classification does this
patient represent?
A. Profile A (warm and dry)
B. Profile B (warm and wet)
C. Profile L (cold and dry)
D. Profile C (cold and wet)
Rationale: Profile C (cold and wet) represents the most hemodynamically compromised
ADHF presentation: inadequate perfusion (cold: low cardiac output evidenced by
hypotension, cool extremities, end-organ hypoperfusion) with congestion (wet: elevated
filling pressures evidenced by JVD, crackles, edema). The Nohria-Stevenson classification
guides therapy: Profile C patients require inotropic support (dobutamine or milrinone) plus
vasodilators or vasopressors depending on blood pressure, and often mechanical circulatory
support. Profile A (warm/dry) is compensated and stable. Profile B (warm/wet) needs
diuresis with vasodilators. Profile L (cold/dry) needs cautious volume expansion and
inotropes.
2. A patient with a left ventricular assist device (LVAD) reports feeling fatigued and noticing the
device's flow rate has decreased from 5.0 to 2.8 L/min. The pump power has also decreased. The
driveline site appears intact. What is the most likely cause?
A. LVAD infection
B. Pump thrombosis
C. Right ventricular failure
D. Driveline fracture
Rationale: Decreased pump flow and power with fatigue are classic signs of LVAD pump
thrombosis. Other indicators include elevated LDH, hemolysis (plasma-free hemoglobin),
and pump alarm events. Confirmation requires echocardiography (evaluating the aortic
valve opening pattern and LV unloading) and CT angiography. Management ranges from
anticoagulation intensification (heparin drip) to thrombolytic therapy or surgical pump
exchange for refractory cases. Driveline fracture would cause a pump stop alarm, not
gradual flow decrease. RV failure would present with systemic congestion (JVD,
hepatomegaly) but not primarily decreased pump parameters. LVAD infection typically
presents with driveline site erythema, drainage, and fever.
3. A patient arrives to the ED with STEMI. Door-to-balloon time is achieved in 62 minutes. Post-
PCI, which medication regimen is initiated per current AHA/ACC guidelines?
A. Aspirin 81 mg daily only
B. Dual antiplatelet therapy (DAPT) with aspirin plus a P2Y12 inhibitor, high-
intensity statin, beta-blocker, and ACE inhibitor
C. Warfarin with INR monitoring
D. Clopidogrel monotherapy
Rationale: Post-PCI guideline-directed medical therapy (GDMT) includes: DAPT (aspirin
81 mg plus P2Y12 inhibitor: clopidogrel, prasugrel, or ticagrelor) for 6-12 months depending
on bleeding risk and stent type; high-intensity statin (atorvastatin 40-80 mg); beta-blocker
(metoprolol succinate or carvedilol) within 24 hours; and ACE inhibitor or ARB (especially
if EF less than 40%, HTN, diabetes, or CKD). The AHA/ACC 2023 guidelines emphasize
early initiation. Door-to-balloon time target is less than 90 minutes; this patient achieved 62
minutes, which is optimal.
4. A patient with severe aortic stenosis (aortic valve area 0.6 cm2, mean gradient 48 mmHg)
presents with syncope, exertional angina, and dyspnea. Ejection fraction is 55%. What is the
definitive treatment?
A. Medical management with diuretics only
1
, B. Surgical aortic valve replacement (SAVR) or transcatheter aortic valve
replacement (TAVR)
C. Aortic balloon valvuloplasty
D. Antibiotic prophylaxis and observation
Rationale: This patient has severe aortic stenosis with classic triad symptoms (syncope,
angina, dyspnea), indicating poor prognosis with medical management alone (average
survival less than 2-3 years with syncope). The 2020 ACC/AHA Valvular Heart Disease
guidelines recommend aortic valve replacement (SAVR or TAVR) as Class I indication for
symptomatic severe AS regardless of EF. TAVR is preferred for patients greater than 75 or
those with high surgical risk (STS score greater than 8%). SAVR remains preferred for
younger patients (less than 65) and those with concomitant coronary artery disease
requiring CABG. Balloon valvuloplasty is a bridge therapy only, not definitive.
Section 2: Cardiac Dysrhythmias and Cardiogenic Shock
5. A patient with atrial fibrillation with rapid ventricular response (HR 152 bpm) is
hemodynamically unstable (BP 78/50, altered mental status, diaphoresis). What is the immediate
nursing action?
A. Administer metoprolol IV
B. Prepare for immediate synchronized cardioversion
C. Administer amiodarone IV drip
D. Apply vagal maneuvers
Rationale: Hemodynamically unstable AFib with RVR (hypotension, altered mental status,
chest pain, acute heart failure) requires immediate synchronized cardioversion per ACLS
guidelines. Synchronized cardioversion delivers a shock timed to the QRS complex to avoid
shocking during the vulnerable repolarization period (T wave), which could precipitate
ventricular fibrillation. Initial energy: 120-200J biphasic. If the patient is stable, rate
control (diltiazem, metoprolol, or amiodarone) or rhythm control strategies are
appropriate. Vagal maneuvers are for stable SVT. Metoprolol would worsen hypotension in
this patient and is contraindicated in hemodynamically unstable patients.
6. A patient in cardiogenic shock has the following hemodynamic parameters: BP 82/50, HR 118,
CVP 18 mmHg, cardiac output 3.2 L/min, SVR 1600 dynes/sec/cm5, PAOP/PCWP 28 mmHg.
Which medication should the nurse anticipate administering?
A. Nitroprusside
B. Norepinephrine
C. Dobutamine
D. Phenylephrine
Rationale: This patient has cardiogenic shock: low cardiac output (3.2 L/min; normal 4-
8), elevated filling pressures (CVP 18, PAOP 28), and adequate-to-elevated SVR (1600). The
primary problem is pump failure, not vasodilation. Dobutamine (a beta-1 agonist inotrope)
is the first-line inotrope for cardiogenic shock to improve cardiac output and myocardial
contractility while causing mild vasodilation. However, if hypotension is severe (MAP less
than 65), norepinephrine is added to maintain coronary perfusion pressure. Nitroprusside
(vasodilator) would worsen hypotension. Phenylephrine (pure alpha agonist) increases
afterload and would further impair cardiac output.
7. A patient with a permanent pacemaker develops hiccups and intermittent pectoral muscle
twitching. What complication does this most likely indicate?
A. Lead fracture
B. Phrenic nerve stimulation from atrial lead placement
C. Pacemaker-mediated tachycardia
D. Endocarditis
Rationale: Unilateral diaphragmatic (phrenic nerve) stimulation and pectoral muscle
twitching indicate that the pacemaker lead is positioned too close to the phrenic nerve or is
delivering excessive output. The phrenic nerve innervates the diaphragm and runs along the
2
