NUR 2502 Multidimensional Care III – Exam 1 Review
(2026) Actual Exam 2026/2027 – Complete Exam-Style
Questions with Detailed Rationales | 100% Verified – Pass
Guaranteed – A+ Graded
Select the single best answer for each question. Each question is worth one point. Choose
the response that best reflects safe, evidence-based complex nursing care.
Cardiovascular and Hematologic Considerations in Complex Care
Q1: A client with a history of heart failure is admitted with a 3-day history of worsening
shortness of breath and a 4-pound weight gain. Which assessment finding requires the
nurse’s immediate intervention?
A. Trace bilateral pedal edema
B. Oxygen saturation of 89% on room air [CORRECT]
C. Heart rate of 88 beats per minute
D. Reports of sleeping with two pillows
Correct Answer: B
Rationale: The best answer is B because an oxygen saturation of 89% indicates acute
hypoxemia requiring immediate supplemental oxygen. This aligns with the ABC priority of
ensuring adequate tissue oxygenation in heart failure exacerbations.
Q2: A client experiencing acute chest pain is prescribed sublingual nitroglycerin. Which
instruction should the nurse provide before administration?
A. "Swallow the tablet whole with a full glass of water."
B. "Take this medication only if your heart rate drops below 60."
C. "Sit or lie down before placing the tablet under your tongue." [CORRECT]
D. "Chew the tablet to speed up the absorption process."
Correct Answer: C
Rationale: This choice is correct because nitroglycerin causes rapid vasodilation, which can
lead to severe orthostatic hypotension and syncope. Sitting or lying down prevents falls and
injury during administration.
Q3: A telemetry nurse notes a client has developed new-onset atrial fibrillation with a rapid
ventricular response. What is the priority nursing action?
A. Administer a scheduled dose of aspirin.
B. Assess the client’s blood pressure and oxygen saturation. [CORRECT]
C. Prepare the client for immediate synchronized cardioversion.
D. Document the rhythm and continue routine monitoring.
Correct Answer: B
,Rationale: In this situation, the priority is to assess hemodynamic stability before
intervening. Checking blood pressure and oxygen saturation determines if the client is stable
or requires emergent synchronized cardioversion.
Q4: A client in cardiogenic shock has a pulmonary artery catheter in place. Which
hemodynamic parameter best supports this diagnosis?
A. Cardiac index of 1.8 L/min/m² and elevated PCWP [CORRECT]
B. Cardiac index of 3.5 L/min/m² and low PCWP
C. Normal cardiac output with decreased systemic vascular resistance
D. Elevated cardiac output with low central venous pressure
Correct Answer: A
Rationale: This matches the expected finding for cardiogenic shock, where the failing heart
pumps poorly (low cardiac index) and blood backs up into the lungs (elevated pulmonary
capillary wedge pressure).
Q5: A client is being discharged with a newly implanted permanent pacemaker. Which
statement by the client indicates a need for further teaching?
A. "I will avoid leaning my cell phone directly over the device."
B. "I can return to playing recreational tennis next week." [CORRECT]
C. "I will check my pulse daily and report significant changes."
D. "I will carry my pacemaker identification card at all times."
Correct Answer: B
Rationale: This choice is correct because vigorous arm movements, like playing tennis, are
restricted for several weeks to prevent lead dislodgement. The other statements reflect
accurate understanding of pacemaker precautions.
Q6: A client is receiving a continuous IV heparin infusion for a deep vein thrombosis. Which
laboratory value should the nurse monitor to evaluate therapeutic effectiveness?
A. Prothrombin time (PT)
B. International Normalized Ratio (INR)
C. Activated partial thromboplastin time (aPTT) [CORRECT]
D. Platelet count
Correct Answer: C
Rationale: The best answer is C because aPTT is the standard laboratory test used to
monitor the therapeutic range of unfractionated heparin. PT and INR are used to monitor
warfarin therapy, not heparin.
Q7: A client on warfarin therapy has an INR of 3.8. The target INR for this client is 2.0 to 3.0.
What is the nurse’s most appropriate action?
A. Administer the scheduled dose of warfarin as ordered.
B. Hold the warfarin dose and notify the healthcare provider. [CORRECT]
C. Administer vitamin K intravenously immediately.
D. Increase the client’s intake of leafy green vegetables.
Correct Answer: B
Rationale: This aligns with the principle that a supratherapeutic INR increases bleeding risk,
requiring the dose to be held and the provider notified. IV vitamin K is typically reserved for
severe bleeding or much higher INR levels.
, Q8: Fifteen minutes after starting a packed red blood cell transfusion, the client reports
chills and lower back pain. What is the nurse’s priority action?
A. Slow the transfusion rate and reassess in 15 minutes.
B. Administer prescribed diphenhydramine and acetaminophen.
C. Stop the transfusion immediately and keep the IV line open with normal saline.
[CORRECT]
D. Obtain a urine specimen to check for hemoglobin.
Correct Answer: C
Rationale: The best answer is C because these are classic signs of an acute hemolytic
transfusion reaction, a medical emergency. Stopping the infusion immediately prevents
further administration of the incompatible blood.
Q9: A client with severe sepsis develops oozing from IV sites and a petechial rash. Which
condition does the nurse suspect?
A. Thrombocytopenia induced by heparin
B. Disseminated intravascular coagulation (DIC) [CORRECT]
C. Immune thrombocytopenic purpura (ITP)
D. Vitamin K deficiency
Correct Answer: B
Rationale: This matches the expected finding for DIC, where widespread microvascular
clotting consumes clotting factors, leading to simultaneous bleeding and thrombosis. Oozing
from puncture sites is a hallmark clinical sign.
Q10: A client with anemia of chronic disease reports severe fatigue. Which nursing
intervention is most appropriate to include in the care plan?
A. Encourage vigorous daily exercise to build stamina.
B. Cluster nursing care to provide uninterrupted rest periods. [CORRECT]
C. Restrict fluid intake to prevent fluid overload.
D. Administer iron supplements on an empty stomach.
Correct Answer: B
Rationale: This choice is correct because clustering care minimizes energy expenditure and
helps manage the profound fatigue associated with anemia. Vigorous exercise would
exacerbate the client’s oxygen demand and fatigue.
Q11: A client with peripheral vascular disease (PVD) reports calf pain that occurs with
walking and resolves with rest. How should the nurse document this finding?
A. Rest pain
B. Intermittent claudication [CORRECT]
C. Venous stasis ulceration
D. Dependent rubor
Correct Answer: B
Rationale: The best answer is B because intermittent claudication is the classic description of
ischemic muscle pain triggered by exertion and relieved by rest in PVD. This helps
differentiate arterial insufficiency from venous disorders.
(2026) Actual Exam 2026/2027 – Complete Exam-Style
Questions with Detailed Rationales | 100% Verified – Pass
Guaranteed – A+ Graded
Select the single best answer for each question. Each question is worth one point. Choose
the response that best reflects safe, evidence-based complex nursing care.
Cardiovascular and Hematologic Considerations in Complex Care
Q1: A client with a history of heart failure is admitted with a 3-day history of worsening
shortness of breath and a 4-pound weight gain. Which assessment finding requires the
nurse’s immediate intervention?
A. Trace bilateral pedal edema
B. Oxygen saturation of 89% on room air [CORRECT]
C. Heart rate of 88 beats per minute
D. Reports of sleeping with two pillows
Correct Answer: B
Rationale: The best answer is B because an oxygen saturation of 89% indicates acute
hypoxemia requiring immediate supplemental oxygen. This aligns with the ABC priority of
ensuring adequate tissue oxygenation in heart failure exacerbations.
Q2: A client experiencing acute chest pain is prescribed sublingual nitroglycerin. Which
instruction should the nurse provide before administration?
A. "Swallow the tablet whole with a full glass of water."
B. "Take this medication only if your heart rate drops below 60."
C. "Sit or lie down before placing the tablet under your tongue." [CORRECT]
D. "Chew the tablet to speed up the absorption process."
Correct Answer: C
Rationale: This choice is correct because nitroglycerin causes rapid vasodilation, which can
lead to severe orthostatic hypotension and syncope. Sitting or lying down prevents falls and
injury during administration.
Q3: A telemetry nurse notes a client has developed new-onset atrial fibrillation with a rapid
ventricular response. What is the priority nursing action?
A. Administer a scheduled dose of aspirin.
B. Assess the client’s blood pressure and oxygen saturation. [CORRECT]
C. Prepare the client for immediate synchronized cardioversion.
D. Document the rhythm and continue routine monitoring.
Correct Answer: B
,Rationale: In this situation, the priority is to assess hemodynamic stability before
intervening. Checking blood pressure and oxygen saturation determines if the client is stable
or requires emergent synchronized cardioversion.
Q4: A client in cardiogenic shock has a pulmonary artery catheter in place. Which
hemodynamic parameter best supports this diagnosis?
A. Cardiac index of 1.8 L/min/m² and elevated PCWP [CORRECT]
B. Cardiac index of 3.5 L/min/m² and low PCWP
C. Normal cardiac output with decreased systemic vascular resistance
D. Elevated cardiac output with low central venous pressure
Correct Answer: A
Rationale: This matches the expected finding for cardiogenic shock, where the failing heart
pumps poorly (low cardiac index) and blood backs up into the lungs (elevated pulmonary
capillary wedge pressure).
Q5: A client is being discharged with a newly implanted permanent pacemaker. Which
statement by the client indicates a need for further teaching?
A. "I will avoid leaning my cell phone directly over the device."
B. "I can return to playing recreational tennis next week." [CORRECT]
C. "I will check my pulse daily and report significant changes."
D. "I will carry my pacemaker identification card at all times."
Correct Answer: B
Rationale: This choice is correct because vigorous arm movements, like playing tennis, are
restricted for several weeks to prevent lead dislodgement. The other statements reflect
accurate understanding of pacemaker precautions.
Q6: A client is receiving a continuous IV heparin infusion for a deep vein thrombosis. Which
laboratory value should the nurse monitor to evaluate therapeutic effectiveness?
A. Prothrombin time (PT)
B. International Normalized Ratio (INR)
C. Activated partial thromboplastin time (aPTT) [CORRECT]
D. Platelet count
Correct Answer: C
Rationale: The best answer is C because aPTT is the standard laboratory test used to
monitor the therapeutic range of unfractionated heparin. PT and INR are used to monitor
warfarin therapy, not heparin.
Q7: A client on warfarin therapy has an INR of 3.8. The target INR for this client is 2.0 to 3.0.
What is the nurse’s most appropriate action?
A. Administer the scheduled dose of warfarin as ordered.
B. Hold the warfarin dose and notify the healthcare provider. [CORRECT]
C. Administer vitamin K intravenously immediately.
D. Increase the client’s intake of leafy green vegetables.
Correct Answer: B
Rationale: This aligns with the principle that a supratherapeutic INR increases bleeding risk,
requiring the dose to be held and the provider notified. IV vitamin K is typically reserved for
severe bleeding or much higher INR levels.
, Q8: Fifteen minutes after starting a packed red blood cell transfusion, the client reports
chills and lower back pain. What is the nurse’s priority action?
A. Slow the transfusion rate and reassess in 15 minutes.
B. Administer prescribed diphenhydramine and acetaminophen.
C. Stop the transfusion immediately and keep the IV line open with normal saline.
[CORRECT]
D. Obtain a urine specimen to check for hemoglobin.
Correct Answer: C
Rationale: The best answer is C because these are classic signs of an acute hemolytic
transfusion reaction, a medical emergency. Stopping the infusion immediately prevents
further administration of the incompatible blood.
Q9: A client with severe sepsis develops oozing from IV sites and a petechial rash. Which
condition does the nurse suspect?
A. Thrombocytopenia induced by heparin
B. Disseminated intravascular coagulation (DIC) [CORRECT]
C. Immune thrombocytopenic purpura (ITP)
D. Vitamin K deficiency
Correct Answer: B
Rationale: This matches the expected finding for DIC, where widespread microvascular
clotting consumes clotting factors, leading to simultaneous bleeding and thrombosis. Oozing
from puncture sites is a hallmark clinical sign.
Q10: A client with anemia of chronic disease reports severe fatigue. Which nursing
intervention is most appropriate to include in the care plan?
A. Encourage vigorous daily exercise to build stamina.
B. Cluster nursing care to provide uninterrupted rest periods. [CORRECT]
C. Restrict fluid intake to prevent fluid overload.
D. Administer iron supplements on an empty stomach.
Correct Answer: B
Rationale: This choice is correct because clustering care minimizes energy expenditure and
helps manage the profound fatigue associated with anemia. Vigorous exercise would
exacerbate the client’s oxygen demand and fatigue.
Q11: A client with peripheral vascular disease (PVD) reports calf pain that occurs with
walking and resolves with rest. How should the nurse document this finding?
A. Rest pain
B. Intermittent claudication [CORRECT]
C. Venous stasis ulceration
D. Dependent rubor
Correct Answer: B
Rationale: The best answer is B because intermittent claudication is the classic description of
ischemic muscle pain triggered by exertion and relieved by rest in PVD. This helps
differentiate arterial insufficiency from venous disorders.
