,NSG 3480 Exam 1 | Questions & Verified
Answers | 2026 Edition | Galen College
1. Which of the following best describes the pathophysiology of myocardial infarction?
A) Progressive thickening of the pericardial sac
B) Reversible ischemia caused by coronary artery spasm
C) Irreversible myocardial cell death due to prolonged ischemia from coronary artery occlusion
D) Inflammation of the myocardium without tissue death
Correct Answer: Irreversible myocardial cell death due to prolonged ischemia from coronary artery
occlusion
Rationale: Myocardial infarction results from sustained ischemia that leads to necrosis of myocardial
cells. It is usually caused by thrombus formation over a ruptured atherosclerotic plaque. The damage is
permanent, unlike angina which is reversible ischemia.
2. The nurse is caring for a patient with acute decompensated heart failure who develops severe
dyspnea and pink, frothy sputum. Which intervention should the nurse implement first?
A) Administer IV furosemide as prescribed
B) Place the patient in high Fowler’s position and administer oxygen
C) Insert an indwelling urinary catheter
D) Obtain a 12-lead electrocardiogram
Correct Answer: Place the patient in high Fowler’s position and administer oxygen
Rationale: The patient is experiencing acute pulmonary edema. Immediate priorities are to improve
oxygenation and reduce venous return by positioning the patient upright. Oxygen relieves hypoxemia.
Diuretics and other medications follow initial positioning and oxygen.
3. The nurse is teaching a patient with heart failure about daily weight monitoring. Which statement
indicates a need for further teaching?
,A) “I will weigh myself at the same time every morning after voiding.”
B) “I will report a weight gain of 2 to 3 pounds in one day or 5 pounds in a week.”
C) “I will wear the same type of clothing each time I weigh myself.”
D) “I will skip weighing myself if I feel well that day.”
Correct Answer: “I will skip weighing myself if I feel well that day.”
Rationale: Daily weights are essential to detect fluid retention early, even when the patient feels well.
Weight gain is often the first sign of decompensation. Consistency in timing, clothing, and recording is
critical.
4. The nurse is monitoring a patient receiving IV furosemide for acute pulmonary edema. Which
assessment finding indicates a therapeutic response?
A) Increased crackles in the lung bases
B) Clear lung sounds and decreased dyspnea
C) Jugular venous distention
D) Weight gain of 1 kg in 24 hours
Correct Answer: Clear lung sounds and decreased dyspnea
Rationale: Furosemide is a loop diuretic that reduces fluid overload. Clearing of lung sounds and relief of
shortness of breath indicate that pulmonary congestion is resolving. Increased crackles, weight gain, and
JVD suggest ongoing fluid excess.
5. The nurse is evaluating a patient’s understanding of warfarin therapy. Which statement indicates
effective teaching?
A) “I can take aspirin for my headaches if needed.”
B) “I will report any unusual bleeding or bruising to my provider.”
C) “I will increase my intake of green leafy vegetables for better nutrition.”
D) “I can stop the medication when my INR is normal.”
, Correct Answer: “I will report any unusual bleeding or bruising to my provider.”
Rationale: Warfarin increases bleeding risk; patients must report signs of bleeding. Aspirin increases
bleeding; vitamin K should be consistent, not increased; the drug should not be stopped abruptly
without medical guidance.
6. The nurse is assessing a patient with fluid volume deficit. Which finding is most indicative?
A) Jugular venous distention
B) Bounding peripheral pulses
C) Orthostatic hypotension and dry mucous membranes
D) Crackles in the lung bases
Correct Answer: Orthostatic hypotension and dry mucous membranes
Rationale: Fluid volume deficit leads to decreased vascular volume, resulting in orthostatic hypotension,
dry mucous membranes, poor skin turgor, and concentrated urine. JVD, bounding pulses, and crackles
indicate fluid volume excess.
7. The nurse is caring for a patient with a chest tube connected to a water-seal drainage system.
Continuous bubbling is noted in the water-seal chamber. What should the nurse do first?
A) Clamp the chest tube immediately
B) Add more sterile water to the chamber
C) Check the system for an air leak, starting at the insertion site
D) Document the finding as normal
Correct Answer: Check the system for an air leak, starting at the insertion site
Rationale: Continuous bubbling in the water-seal chamber indicates an air leak in the drainage system.
The nurse must systematically check connections and the insertion site to locate and correct the leak.
Clamping without an order is contraindicated.
Answers | 2026 Edition | Galen College
1. Which of the following best describes the pathophysiology of myocardial infarction?
A) Progressive thickening of the pericardial sac
B) Reversible ischemia caused by coronary artery spasm
C) Irreversible myocardial cell death due to prolonged ischemia from coronary artery occlusion
D) Inflammation of the myocardium without tissue death
Correct Answer: Irreversible myocardial cell death due to prolonged ischemia from coronary artery
occlusion
Rationale: Myocardial infarction results from sustained ischemia that leads to necrosis of myocardial
cells. It is usually caused by thrombus formation over a ruptured atherosclerotic plaque. The damage is
permanent, unlike angina which is reversible ischemia.
2. The nurse is caring for a patient with acute decompensated heart failure who develops severe
dyspnea and pink, frothy sputum. Which intervention should the nurse implement first?
A) Administer IV furosemide as prescribed
B) Place the patient in high Fowler’s position and administer oxygen
C) Insert an indwelling urinary catheter
D) Obtain a 12-lead electrocardiogram
Correct Answer: Place the patient in high Fowler’s position and administer oxygen
Rationale: The patient is experiencing acute pulmonary edema. Immediate priorities are to improve
oxygenation and reduce venous return by positioning the patient upright. Oxygen relieves hypoxemia.
Diuretics and other medications follow initial positioning and oxygen.
3. The nurse is teaching a patient with heart failure about daily weight monitoring. Which statement
indicates a need for further teaching?
,A) “I will weigh myself at the same time every morning after voiding.”
B) “I will report a weight gain of 2 to 3 pounds in one day or 5 pounds in a week.”
C) “I will wear the same type of clothing each time I weigh myself.”
D) “I will skip weighing myself if I feel well that day.”
Correct Answer: “I will skip weighing myself if I feel well that day.”
Rationale: Daily weights are essential to detect fluid retention early, even when the patient feels well.
Weight gain is often the first sign of decompensation. Consistency in timing, clothing, and recording is
critical.
4. The nurse is monitoring a patient receiving IV furosemide for acute pulmonary edema. Which
assessment finding indicates a therapeutic response?
A) Increased crackles in the lung bases
B) Clear lung sounds and decreased dyspnea
C) Jugular venous distention
D) Weight gain of 1 kg in 24 hours
Correct Answer: Clear lung sounds and decreased dyspnea
Rationale: Furosemide is a loop diuretic that reduces fluid overload. Clearing of lung sounds and relief of
shortness of breath indicate that pulmonary congestion is resolving. Increased crackles, weight gain, and
JVD suggest ongoing fluid excess.
5. The nurse is evaluating a patient’s understanding of warfarin therapy. Which statement indicates
effective teaching?
A) “I can take aspirin for my headaches if needed.”
B) “I will report any unusual bleeding or bruising to my provider.”
C) “I will increase my intake of green leafy vegetables for better nutrition.”
D) “I can stop the medication when my INR is normal.”
, Correct Answer: “I will report any unusual bleeding or bruising to my provider.”
Rationale: Warfarin increases bleeding risk; patients must report signs of bleeding. Aspirin increases
bleeding; vitamin K should be consistent, not increased; the drug should not be stopped abruptly
without medical guidance.
6. The nurse is assessing a patient with fluid volume deficit. Which finding is most indicative?
A) Jugular venous distention
B) Bounding peripheral pulses
C) Orthostatic hypotension and dry mucous membranes
D) Crackles in the lung bases
Correct Answer: Orthostatic hypotension and dry mucous membranes
Rationale: Fluid volume deficit leads to decreased vascular volume, resulting in orthostatic hypotension,
dry mucous membranes, poor skin turgor, and concentrated urine. JVD, bounding pulses, and crackles
indicate fluid volume excess.
7. The nurse is caring for a patient with a chest tube connected to a water-seal drainage system.
Continuous bubbling is noted in the water-seal chamber. What should the nurse do first?
A) Clamp the chest tube immediately
B) Add more sterile water to the chamber
C) Check the system for an air leak, starting at the insertion site
D) Document the finding as normal
Correct Answer: Check the system for an air leak, starting at the insertion site
Rationale: Continuous bubbling in the water-seal chamber indicates an air leak in the drainage system.
The nurse must systematically check connections and the insertion site to locate and correct the leak.
Clamping without an order is contraindicated.
