NSG 4100 (Adult Health III) Exam 3 Practice Questions
140 Questions with Multiple Choice Answers & Explanations
in Italics
Question 1
A patient presents with chest pain radiating to the jaw, diaphoresis, and nausea. Which
actions should the nurse take? Select all that apply.
A) Administer sublingual nitroglycerin
B) Obtain a 12-lead ECG
C) Administer morphine sulfate for pain
D) Encourage the patient to ambulate to reduce anxiety
E) Check cardiac enzymes
F) Apply oxygen at 2 L/min via nasal cannula
Correct Answers: A, B, C, E, F
Rationale: A, B, C, E, F are correct interventions for suspected myocardial infarction.
Nitroglycerin vasodilates coronary arteries. ECG and cardiac enzymes confirm diagnosis.
Morphine reduces preload and pain. Oxygen improves myocardial oxygenation.
Ambulation (D) is incorrect because activity increases myocardial oxygen demand and is
dangerous during an acute MI.
Question 2
The nurse is assessing a patient with atrial fibrillation. Which findings should the nurse
expect? Select all that apply.
A) Irregularly irregular heart rhythm
B) Absent P waves on ECG
C) Ventricular rate of 150 bpm
D) Regular sawtooth pattern on ECG
,E) Risk of thrombus formation
F) Normal sinus rhythm on monitor
Correct Answers: A, B, C, E
*Rationale: A-F. Atrial fibrillation presents with irregularly irregular rhythm, absent P
waves (replaced by fibrillatory waves), rapid ventricular response (often 120-180 bpm),
and increased stroke risk from atrial thrombi. Sawtooth pattern (D) is atrial flutter.
Normal sinus rhythm (F) is not present in AF.*
Question 3
A patient with heart failure has jugular vein distention, 3+ pitting edema, and crackles in
lung bases. Which hemodynamic findings should the nurse expect? Select all that
apply.
A) Elevated PAWP (>18 mm Hg)
B) Elevated CVP (>6 mm Hg)
C) Decreased cardiac output
D) Decreased SVR
E) Normal PAWP
F) Increased urine output
Correct Answers: A, B, C
Rationale: In decompensated heart failure, PAWP (preload) is elevated due to fluid backup
into lungs. CVP is elevated from right-sided failure. Cardiac output decreases as the failing
heart cannot pump effectively. SVR increases (not decreases, D) as compensation. Urine
output decreases (not increases, F) from reduced renal perfusion.
Question 4
The nurse is caring for a patient with cardiac tamponade. Which findings support this
diagnosis? Select all that apply.
,A) Muffled heart sounds
B) Distended jugular veins
C) Hypotension
D) Bounding peripheral pulses
E) Pulsus paradoxus >10 mm Hg
F) Increased urine output
Correct Answers: A, B, C, E
*Rationale: Beck's triad for tamponade includes muffled heart sounds, JVD, and
hypotension. Pulsus paradoxus (exaggerated drop in systolic BP during inspiration >10
mm Hg) is also present. Bounding pulses (D) occur in high-output states. Urine output
decreases (not increases, F) due to low cardiac output.*
Question 5
Which interventions should the nurse implement for a patient with symptomatic
bradycardia (HR 35 bpm, BP 85/50)? Select all that apply.
A) Prepare for transcutaneous pacing
B) Administer atropine 0.5 mg IV push
C) Place patient in Trendelenburg position
D) Monitor blood pressure every 5 minutes
E) Administer adenosine 6 mg rapid IV push
F) Prepare for defibrillation
Correct Answers: A, B, D
Rationale: For symptomatic bradycardia with hypotension, pacing and atropine are first-
line. BP monitoring guides treatment response. Trendelenburg (C) increases preload but
not indicated here. Adenosine (E) treats tachyarrhythmias. Defibrillation (F) treats pulseless
VT/VF.
Question 6
, A patient has an INR of 5.8 while receiving warfarin for atrial fibrillation. Which actions
should the nurse take? Select all that apply.
A) Notify the healthcare provider immediately
B) Prepare to administer vitamin K
C) Continue warfarin as ordered
D) Assess for signs of bleeding
E) Hold the next dose of warfarin
F) Administer protamine sulfate
Correct Answers: A, B, D, E
*Rationale: INR 5.8 is supratherapeutic (goal 2-3). Provider notification, holding warfarin,
assessing for bleeding, and preparing vitamin K (antidote) are correct. Continuing
warfarin (C) worsens bleeding risk. Protamine sulfate (F) reverses heparin, not warfarin.*
Question 7
The nurse is monitoring a patient receiving a heparin infusion. Which laboratory values
indicate therapeutic anticoagulation? Select all that apply. (Normal aPTT 25-35 sec)
A) aPTT 30 seconds
B) aPTT 50 seconds
C) aPTT 65 seconds
D) aPTT 80 seconds
E) INR 2.5
F) Platelet count 50,000/mm³
Correct Answers: B, C
*Rationale: Therapeutic aPTT for heparin is 1.5-2.5 times normal. With normal 25-35 sec,
therapeutic range is approximately 46-70 sec. 50 sec and 65 sec fall within this range. 30
sec (A) is subtherapeutic. 80 sec (D) is supratherapeutic. INR (E) monitors warfarin.
Platelet count (F) monitors for HIT.*
140 Questions with Multiple Choice Answers & Explanations
in Italics
Question 1
A patient presents with chest pain radiating to the jaw, diaphoresis, and nausea. Which
actions should the nurse take? Select all that apply.
A) Administer sublingual nitroglycerin
B) Obtain a 12-lead ECG
C) Administer morphine sulfate for pain
D) Encourage the patient to ambulate to reduce anxiety
E) Check cardiac enzymes
F) Apply oxygen at 2 L/min via nasal cannula
Correct Answers: A, B, C, E, F
Rationale: A, B, C, E, F are correct interventions for suspected myocardial infarction.
Nitroglycerin vasodilates coronary arteries. ECG and cardiac enzymes confirm diagnosis.
Morphine reduces preload and pain. Oxygen improves myocardial oxygenation.
Ambulation (D) is incorrect because activity increases myocardial oxygen demand and is
dangerous during an acute MI.
Question 2
The nurse is assessing a patient with atrial fibrillation. Which findings should the nurse
expect? Select all that apply.
A) Irregularly irregular heart rhythm
B) Absent P waves on ECG
C) Ventricular rate of 150 bpm
D) Regular sawtooth pattern on ECG
,E) Risk of thrombus formation
F) Normal sinus rhythm on monitor
Correct Answers: A, B, C, E
*Rationale: A-F. Atrial fibrillation presents with irregularly irregular rhythm, absent P
waves (replaced by fibrillatory waves), rapid ventricular response (often 120-180 bpm),
and increased stroke risk from atrial thrombi. Sawtooth pattern (D) is atrial flutter.
Normal sinus rhythm (F) is not present in AF.*
Question 3
A patient with heart failure has jugular vein distention, 3+ pitting edema, and crackles in
lung bases. Which hemodynamic findings should the nurse expect? Select all that
apply.
A) Elevated PAWP (>18 mm Hg)
B) Elevated CVP (>6 mm Hg)
C) Decreased cardiac output
D) Decreased SVR
E) Normal PAWP
F) Increased urine output
Correct Answers: A, B, C
Rationale: In decompensated heart failure, PAWP (preload) is elevated due to fluid backup
into lungs. CVP is elevated from right-sided failure. Cardiac output decreases as the failing
heart cannot pump effectively. SVR increases (not decreases, D) as compensation. Urine
output decreases (not increases, F) from reduced renal perfusion.
Question 4
The nurse is caring for a patient with cardiac tamponade. Which findings support this
diagnosis? Select all that apply.
,A) Muffled heart sounds
B) Distended jugular veins
C) Hypotension
D) Bounding peripheral pulses
E) Pulsus paradoxus >10 mm Hg
F) Increased urine output
Correct Answers: A, B, C, E
*Rationale: Beck's triad for tamponade includes muffled heart sounds, JVD, and
hypotension. Pulsus paradoxus (exaggerated drop in systolic BP during inspiration >10
mm Hg) is also present. Bounding pulses (D) occur in high-output states. Urine output
decreases (not increases, F) due to low cardiac output.*
Question 5
Which interventions should the nurse implement for a patient with symptomatic
bradycardia (HR 35 bpm, BP 85/50)? Select all that apply.
A) Prepare for transcutaneous pacing
B) Administer atropine 0.5 mg IV push
C) Place patient in Trendelenburg position
D) Monitor blood pressure every 5 minutes
E) Administer adenosine 6 mg rapid IV push
F) Prepare for defibrillation
Correct Answers: A, B, D
Rationale: For symptomatic bradycardia with hypotension, pacing and atropine are first-
line. BP monitoring guides treatment response. Trendelenburg (C) increases preload but
not indicated here. Adenosine (E) treats tachyarrhythmias. Defibrillation (F) treats pulseless
VT/VF.
Question 6
, A patient has an INR of 5.8 while receiving warfarin for atrial fibrillation. Which actions
should the nurse take? Select all that apply.
A) Notify the healthcare provider immediately
B) Prepare to administer vitamin K
C) Continue warfarin as ordered
D) Assess for signs of bleeding
E) Hold the next dose of warfarin
F) Administer protamine sulfate
Correct Answers: A, B, D, E
*Rationale: INR 5.8 is supratherapeutic (goal 2-3). Provider notification, holding warfarin,
assessing for bleeding, and preparing vitamin K (antidote) are correct. Continuing
warfarin (C) worsens bleeding risk. Protamine sulfate (F) reverses heparin, not warfarin.*
Question 7
The nurse is monitoring a patient receiving a heparin infusion. Which laboratory values
indicate therapeutic anticoagulation? Select all that apply. (Normal aPTT 25-35 sec)
A) aPTT 30 seconds
B) aPTT 50 seconds
C) aPTT 65 seconds
D) aPTT 80 seconds
E) INR 2.5
F) Platelet count 50,000/mm³
Correct Answers: B, C
*Rationale: Therapeutic aPTT for heparin is 1.5-2.5 times normal. With normal 25-35 sec,
therapeutic range is approximately 46-70 sec. 50 sec and 65 sec fall within this range. 30
sec (A) is subtherapeutic. 80 sec (D) is supratherapeutic. INR (E) monitors warfarin.
Platelet count (F) monitors for HIT.*
