NUR 122 – Medical-Surgical Nursing II | Advanced
Study Guide, Complex Adult Health Conditions,
Nursing Management, Clinical Decision-Making,
Practice Questions, and Examination Preparation
1. A 67-year-old male patient with a history of hypertension and type 2
diabetes presents to the emergency department with acute substernal
chest pain radiating to the jaw. ECG shows ST-segment elevation in leads
V1-V4. His vital signs are BP 145/92, HR 102, RR 22, SpO2 94% on room
air. What is the priority nursing intervention?
A) Administer sublingual nitroglycerin
B) Obtain a 12-lead ECG
C) Prepare for immediate percutaneous coronary intervention (PCI)
D) Administer morphine sulfate for pain
Answer: C
Rationale: STEMI requires immediate reperfusion therapy. PCI is the gold
standard if available within 90 minutes of arrival. The priority nursing action
is to prepare the patient for PCI while administering aspirin, oxygen, and
nitroglycerin. This aligns with the American Heart Association guidelines for
STEMI management.
2. A 72-year-old female patient with heart failure with reduced ejection
fraction (HFrEF) presents with worsening dyspnea, orthopnea, and 3+
pitting edema in both lower extremities. Her medications include
carvedilol, lisinopril, furosemide, and spironolactone. Laboratory
results show potassium 6.1 mEq/L and creatinine 2.8 mg/dL. Which
medication should the nurse question administering?
A) Carvedilol
B) Lisinopril
C) Furosemide
D) Spironolactone
,Answer: D
Rationale: Spironolactone is a potassium-sparing diuretic that can cause life-
threatening hyperkalemia, especially when combined with ACE inhibitors and
in patients with renal impairment. The nurse should hold the spironolactone
and notify the healthcare provider. Potassium level >5.5 mEq/L requires
immediate intervention.
3. A 58-year-old male patient is admitted with acute exacerbation of
heart failure. He is receiving IV furosemide. Which assessment finding
indicates a therapeutic response to the medication?
A) Increased blood pressure
B) Decreased heart rate
C) Increased urine output and decreased dyspnea
D) Decreased serum potassium level
Answer: C
Rationale: Furosemide is a loop diuretic that reduces preload by promoting
diuresis. Therapeutic response is indicated by increased urine output,
decreased dyspnea, decreased edema, and decreased jugular venous
distension. Monitoring daily weights and I&O is essential.
4. A 65-year-old patient with atrial fibrillation is prescribed warfarin.
The nurse should monitor which laboratory value to evaluate the
effectiveness of this medication?
A) Platelet count
B) aPTT
C) INR
D) PT
Answer: C
Rationale: Warfarin is a vitamin K antagonist that prolongs the prothrombin
time. The INR is the standardized measure used to monitor warfarin therapy.
For atrial fibrillation, the target INR is typically 2.0-3.0. PT is the raw value;
INR accounts for reagent variations.
,5. A 55-year-old patient is 2 days post-operative following coronary
artery bypass graft surgery. The nurse notes new-onset atrial fibrillation
with a ventricular rate of 150 bpm. The patient is hemodynamically
stable. Which medication would the nurse anticipate administering?
A) Amiodarone IV
B) Adenosine IV
C) Diltiazem IV
D) Metoprolol IV
Answer: D
Rationale: Beta-blockers are first-line for rate control in post-operative atrial
fibrillation. Metoprolol IV can be given for rapid rate control. Amiodarone is
used for rhythm control in hemodynamically unstable patients. Adenosine is
for supraventricular tachycardia.
6. A 62-year-old patient with a history of peripheral artery disease
complains of left calf pain when walking that resolves with rest. Which
nursing diagnosis is most appropriate for this patient?
A) Acute pain related to tissue ischemia
B) Ineffective peripheral tissue perfusion related to atherosclerosis
C) Activity intolerance related to decreased oxygen supply to muscles
D) Risk for injury related to impaired mobility
Answer: B
Rationale: Intermittent claudication is a classic symptom of peripheral artery
disease. The underlying pathophysiology is atherosclerosis causing decreased
arterial blood flow. The primary nursing diagnosis addresses the impaired
tissue perfusion. While activity intolerance is related, the underlying cause
must be addressed.
7. A 45-year-old patient with deep vein thrombosis (DVT) is receiving
heparin infusion. The nurse notes an aPTT of 98 seconds (normal 25-
35). What is the most appropriate nursing action?
, A) Continue the infusion as ordered
B) Increase the infusion rate
C) Decrease the infusion rate or hold the infusion
D) Administer vitamin K
Answer: C
Rationale: Therapeutic aPTT for heparin is 1.5-2.5 times the normal value
(60-85 seconds). An aPTT of 98 seconds exceeds the therapeutic range and
increases bleeding risk. The nurse should notify the provider and decrease or
hold the infusion. Protamine sulfate is the antidote for heparin.
8. A 70-year-old patient with aortic stenosis presents with syncope and
chest pain. The nurse understands that these symptoms are primarily
caused by which mechanism?
A) Decreased cardiac output due to left ventricular outflow obstruction
B) Increased left ventricular end-diastolic pressure
C) Coronary artery vasospasm
D) Right ventricular failure
Answer: A
Rationale: Aortic stenosis causes left ventricular outflow obstruction, leading
to decreased cardiac output. The classic triad includes syncope, angina, and
dyspnea. Syncope occurs due to cerebral hypoperfusion. Increased LV end-
diastolic pressure contributes to dyspnea.
9. A 52-year-old patient is diagnosed with hypertensive urgency with a
blood pressure of 200/120 mmHg. The patient is asymptomatic. Which
intervention is most appropriate?
A) Admit to ICU for IV antihypertensive therapy
B) Administer sublingual nifedipine
C) Initiate oral antihypertensive medication and monitor
D) Administer IV labetalol
Answer: C
Rationale: Hypertensive urgency involves severe hypertension without acute
Study Guide, Complex Adult Health Conditions,
Nursing Management, Clinical Decision-Making,
Practice Questions, and Examination Preparation
1. A 67-year-old male patient with a history of hypertension and type 2
diabetes presents to the emergency department with acute substernal
chest pain radiating to the jaw. ECG shows ST-segment elevation in leads
V1-V4. His vital signs are BP 145/92, HR 102, RR 22, SpO2 94% on room
air. What is the priority nursing intervention?
A) Administer sublingual nitroglycerin
B) Obtain a 12-lead ECG
C) Prepare for immediate percutaneous coronary intervention (PCI)
D) Administer morphine sulfate for pain
Answer: C
Rationale: STEMI requires immediate reperfusion therapy. PCI is the gold
standard if available within 90 minutes of arrival. The priority nursing action
is to prepare the patient for PCI while administering aspirin, oxygen, and
nitroglycerin. This aligns with the American Heart Association guidelines for
STEMI management.
2. A 72-year-old female patient with heart failure with reduced ejection
fraction (HFrEF) presents with worsening dyspnea, orthopnea, and 3+
pitting edema in both lower extremities. Her medications include
carvedilol, lisinopril, furosemide, and spironolactone. Laboratory
results show potassium 6.1 mEq/L and creatinine 2.8 mg/dL. Which
medication should the nurse question administering?
A) Carvedilol
B) Lisinopril
C) Furosemide
D) Spironolactone
,Answer: D
Rationale: Spironolactone is a potassium-sparing diuretic that can cause life-
threatening hyperkalemia, especially when combined with ACE inhibitors and
in patients with renal impairment. The nurse should hold the spironolactone
and notify the healthcare provider. Potassium level >5.5 mEq/L requires
immediate intervention.
3. A 58-year-old male patient is admitted with acute exacerbation of
heart failure. He is receiving IV furosemide. Which assessment finding
indicates a therapeutic response to the medication?
A) Increased blood pressure
B) Decreased heart rate
C) Increased urine output and decreased dyspnea
D) Decreased serum potassium level
Answer: C
Rationale: Furosemide is a loop diuretic that reduces preload by promoting
diuresis. Therapeutic response is indicated by increased urine output,
decreased dyspnea, decreased edema, and decreased jugular venous
distension. Monitoring daily weights and I&O is essential.
4. A 65-year-old patient with atrial fibrillation is prescribed warfarin.
The nurse should monitor which laboratory value to evaluate the
effectiveness of this medication?
A) Platelet count
B) aPTT
C) INR
D) PT
Answer: C
Rationale: Warfarin is a vitamin K antagonist that prolongs the prothrombin
time. The INR is the standardized measure used to monitor warfarin therapy.
For atrial fibrillation, the target INR is typically 2.0-3.0. PT is the raw value;
INR accounts for reagent variations.
,5. A 55-year-old patient is 2 days post-operative following coronary
artery bypass graft surgery. The nurse notes new-onset atrial fibrillation
with a ventricular rate of 150 bpm. The patient is hemodynamically
stable. Which medication would the nurse anticipate administering?
A) Amiodarone IV
B) Adenosine IV
C) Diltiazem IV
D) Metoprolol IV
Answer: D
Rationale: Beta-blockers are first-line for rate control in post-operative atrial
fibrillation. Metoprolol IV can be given for rapid rate control. Amiodarone is
used for rhythm control in hemodynamically unstable patients. Adenosine is
for supraventricular tachycardia.
6. A 62-year-old patient with a history of peripheral artery disease
complains of left calf pain when walking that resolves with rest. Which
nursing diagnosis is most appropriate for this patient?
A) Acute pain related to tissue ischemia
B) Ineffective peripheral tissue perfusion related to atherosclerosis
C) Activity intolerance related to decreased oxygen supply to muscles
D) Risk for injury related to impaired mobility
Answer: B
Rationale: Intermittent claudication is a classic symptom of peripheral artery
disease. The underlying pathophysiology is atherosclerosis causing decreased
arterial blood flow. The primary nursing diagnosis addresses the impaired
tissue perfusion. While activity intolerance is related, the underlying cause
must be addressed.
7. A 45-year-old patient with deep vein thrombosis (DVT) is receiving
heparin infusion. The nurse notes an aPTT of 98 seconds (normal 25-
35). What is the most appropriate nursing action?
, A) Continue the infusion as ordered
B) Increase the infusion rate
C) Decrease the infusion rate or hold the infusion
D) Administer vitamin K
Answer: C
Rationale: Therapeutic aPTT for heparin is 1.5-2.5 times the normal value
(60-85 seconds). An aPTT of 98 seconds exceeds the therapeutic range and
increases bleeding risk. The nurse should notify the provider and decrease or
hold the infusion. Protamine sulfate is the antidote for heparin.
8. A 70-year-old patient with aortic stenosis presents with syncope and
chest pain. The nurse understands that these symptoms are primarily
caused by which mechanism?
A) Decreased cardiac output due to left ventricular outflow obstruction
B) Increased left ventricular end-diastolic pressure
C) Coronary artery vasospasm
D) Right ventricular failure
Answer: A
Rationale: Aortic stenosis causes left ventricular outflow obstruction, leading
to decreased cardiac output. The classic triad includes syncope, angina, and
dyspnea. Syncope occurs due to cerebral hypoperfusion. Increased LV end-
diastolic pressure contributes to dyspnea.
9. A 52-year-old patient is diagnosed with hypertensive urgency with a
blood pressure of 200/120 mmHg. The patient is asymptomatic. Which
intervention is most appropriate?
A) Admit to ICU for IV antihypertensive therapy
B) Administer sublingual nifedipine
C) Initiate oral antihypertensive medication and monitor
D) Administer IV labetalol
Answer: C
Rationale: Hypertensive urgency involves severe hypertension without acute
