Galen NUR280 - 2026/2027 Rated A Guide |
Transition to RN Practice | Comprehensive Exam
Review | 100% Correct Verified Answers
MODULE A: THE "A" STUDENT'S CONCEPTUAL FRAMEWORK
1. Proactive Intervention Model (2026)
Stable → At-Risk → Unstable
Stable: 30-min rounds, trend labs, teach-back, early mobilization.
At-Risk: 15-min surveillance, anticipate orders (K <3.5 → K-rider ready), preload
antibiotics, position for airway, notify provider of trajectory.
Unstable: 5-min cycles, life-saving protocol activated, bring code cart, anticipate
intubation/pressors, document every minute, communicate to family.
2. Differential Prioritization Matrix
Imminent Threat (cardiac arrest, airway loss) wins over Rapid Decline (K 2.8 with
PVCs) wins over Distress (family screaming). Use numeric weight: Threat = 3,
Decline = 2, Distress = 1; highest total score determines first bed.
3. "Beyond the Side Effect" Pharmacology (2026 Update)
ACE-I/ARB: Mechanism ↓ aldosterone → K retention; proactive: if SCr >1.5 or
eGFR <45, expect K >5 at day 3-5; obtain BMP before discharge teaching.
Amiodarone: Inhibits CYP3A4 → ↑ digoxin, ↑ warfarin; proactive: check dig level
and INR 48 h after initiation.
Corticosteroids: ↓ neutrophil adhesion → no rise in WBC despite infection;
proactive: monitor temp trend, not WBC.
Insulin (IV): Binds to IV tubing; proactive: flush 20 mL after loading dose, check
line adsorption policy.
Diltiazem: ↓ CYP1A2 → ↑ theophylline; proactive: hold theophylline if level
unavailable.
Phenobarbital: Induces UGT → ↓ bilirubin, ↓ contraceptives; proactive: alternate
birth control, monitor bilirubin in neonates.
Norepinephrine: Extravasation risk via α1; proactive: insert central line within 2 h,
document insertion site q2h.
, Vancomycin: AUC/MIC target 400-600; proactive: order trough ×1 at 18 h, then
AUC calculator in EHR.
Direct oral anticoagulants (DOACs): CrCl <30 → ↓ dose; proactive: pharmacy
auto-consult triggered.
Thrombolytics: Plasminogen activation → bleeding; proactive: place arterial line
before infusion if possible, avoid unnecessary sticks for 24 h.
MODULE B: "RATED A" ASSESSMENT SIMULATION (80 Advanced Items)
Tier 1: Analysis (Questions 1-30) – All options correct, choose BEST
[Q1] Tier1/MC. A 66-year-old post-TURP has continuous bladder irrigation at 150 mL/h.
At 0800 the output is cherry-red with 2 cm clots. BP 128/78, HR 82. Which action is
MOST indicative of "A" level clinical judgment?
A) Slow the irrigation rate to 100 mL/h to avoid trauma
B) Milk the catheter toward the drainage bag to evacuate clots
C) Increase the irrigation to 200 mL/h and notify urology now
D) Document color and reassess in 30 minutes
[Q2] Tier1/SATA. A patient with septic shock on norepinephrine 0.15 mcg/kg/min has
MAP 58 after 40 mL/kg crystalloid. ScvO2 65%, Hgb 7.8 g/dL. Which interventions
reflect "A" level anticipation of evidence-based goals? (Select all)
A) Transfuse 1 unit PRBC now
B) Start vasopressin 0.03 units/min
C) Obtain echocardiogram to assess EF
D) Decrease norepinephrine to 0.08
E) Check A-V lactate gradient
,[Q3] Tier1/MC. A patient with DKA has glucose 380 mg/dL, K 3.0 mEq/L, pH 7.1. Anion
gap 24. Which action distinguishes an "A" student from a "B" student?
A) Start insulin 0.1 unit/kg/h immediately
B) Give KCl 40 mEq IVPB over 2 h before insulin
C) Obtain BMP again in 1 h
D) Switch to 0.45% NS at 250 mL/h
[Q4] Tier1/Ordered Response. Rank these actions for a 3-day post-craniotomy patient
with sudden ICP 24 mmHg and BP 160/90 (1 = first).
A) Elevate head of bed 30° midline
B) Administer mannitol 1 g/kg IV
C) Check drain waveform for occlusion
D) Hyperventilate to PaCO2 30
[Q5] Tier1/SATA. A patient with HIT has platelet 60,000, aPTT 90 on heparin. Argatroban
is ordered. Which "A" level safety checks are required before starting? (Select all)
A) Verify aPTT <60 sec off heparin
B) Ensure total bilirubin <3 mg/dL
C) Obtain baseline INR
D) Check hepatic panel because argatroban is hepatically cleared
E) Stop all LMWH flushes
, [Q6] Tier1/MC. A patient with heart failure (EF 20%) is on Entresto (sacubitril/valsartan)
and reports persistent cough. Which action shows "A" level differentiation?
A) Switch to ACE-I
B) Hold Entresto and start ARB alone
C) Explain that valsartan rarely causes cough and assess for pulmonary edema
D) Order chest X-ray to rule out pneumonia
[Q7] Tier1/SATA. During moderate sedation with propofol, the patient’s EtCO2 waveform
suddenly loses plateau and becomes low amplitude. Which "A" level responses are
appropriate? (Select all)
A) Increase propofol to deepen sedation
B) Check airway patency
C) Apply jaw thrust
D) Prepare for insertion of LMA
E) Increase oxygen flow
[Q8] Tier1/MC. A patient with Crohn’s on infliximab has LFTs 3× ULN. Which monitoring
plan reflects "A" level foresight?
A) Stop infliximab permanently
B) Continue and recheck LFTs monthly
C) Hold dose, obtain hepatitis panel and TB gold, recheck in 2 weeks
D) Reduce dose by 50%
Transition to RN Practice | Comprehensive Exam
Review | 100% Correct Verified Answers
MODULE A: THE "A" STUDENT'S CONCEPTUAL FRAMEWORK
1. Proactive Intervention Model (2026)
Stable → At-Risk → Unstable
Stable: 30-min rounds, trend labs, teach-back, early mobilization.
At-Risk: 15-min surveillance, anticipate orders (K <3.5 → K-rider ready), preload
antibiotics, position for airway, notify provider of trajectory.
Unstable: 5-min cycles, life-saving protocol activated, bring code cart, anticipate
intubation/pressors, document every minute, communicate to family.
2. Differential Prioritization Matrix
Imminent Threat (cardiac arrest, airway loss) wins over Rapid Decline (K 2.8 with
PVCs) wins over Distress (family screaming). Use numeric weight: Threat = 3,
Decline = 2, Distress = 1; highest total score determines first bed.
3. "Beyond the Side Effect" Pharmacology (2026 Update)
ACE-I/ARB: Mechanism ↓ aldosterone → K retention; proactive: if SCr >1.5 or
eGFR <45, expect K >5 at day 3-5; obtain BMP before discharge teaching.
Amiodarone: Inhibits CYP3A4 → ↑ digoxin, ↑ warfarin; proactive: check dig level
and INR 48 h after initiation.
Corticosteroids: ↓ neutrophil adhesion → no rise in WBC despite infection;
proactive: monitor temp trend, not WBC.
Insulin (IV): Binds to IV tubing; proactive: flush 20 mL after loading dose, check
line adsorption policy.
Diltiazem: ↓ CYP1A2 → ↑ theophylline; proactive: hold theophylline if level
unavailable.
Phenobarbital: Induces UGT → ↓ bilirubin, ↓ contraceptives; proactive: alternate
birth control, monitor bilirubin in neonates.
Norepinephrine: Extravasation risk via α1; proactive: insert central line within 2 h,
document insertion site q2h.
, Vancomycin: AUC/MIC target 400-600; proactive: order trough ×1 at 18 h, then
AUC calculator in EHR.
Direct oral anticoagulants (DOACs): CrCl <30 → ↓ dose; proactive: pharmacy
auto-consult triggered.
Thrombolytics: Plasminogen activation → bleeding; proactive: place arterial line
before infusion if possible, avoid unnecessary sticks for 24 h.
MODULE B: "RATED A" ASSESSMENT SIMULATION (80 Advanced Items)
Tier 1: Analysis (Questions 1-30) – All options correct, choose BEST
[Q1] Tier1/MC. A 66-year-old post-TURP has continuous bladder irrigation at 150 mL/h.
At 0800 the output is cherry-red with 2 cm clots. BP 128/78, HR 82. Which action is
MOST indicative of "A" level clinical judgment?
A) Slow the irrigation rate to 100 mL/h to avoid trauma
B) Milk the catheter toward the drainage bag to evacuate clots
C) Increase the irrigation to 200 mL/h and notify urology now
D) Document color and reassess in 30 minutes
[Q2] Tier1/SATA. A patient with septic shock on norepinephrine 0.15 mcg/kg/min has
MAP 58 after 40 mL/kg crystalloid. ScvO2 65%, Hgb 7.8 g/dL. Which interventions
reflect "A" level anticipation of evidence-based goals? (Select all)
A) Transfuse 1 unit PRBC now
B) Start vasopressin 0.03 units/min
C) Obtain echocardiogram to assess EF
D) Decrease norepinephrine to 0.08
E) Check A-V lactate gradient
,[Q3] Tier1/MC. A patient with DKA has glucose 380 mg/dL, K 3.0 mEq/L, pH 7.1. Anion
gap 24. Which action distinguishes an "A" student from a "B" student?
A) Start insulin 0.1 unit/kg/h immediately
B) Give KCl 40 mEq IVPB over 2 h before insulin
C) Obtain BMP again in 1 h
D) Switch to 0.45% NS at 250 mL/h
[Q4] Tier1/Ordered Response. Rank these actions for a 3-day post-craniotomy patient
with sudden ICP 24 mmHg and BP 160/90 (1 = first).
A) Elevate head of bed 30° midline
B) Administer mannitol 1 g/kg IV
C) Check drain waveform for occlusion
D) Hyperventilate to PaCO2 30
[Q5] Tier1/SATA. A patient with HIT has platelet 60,000, aPTT 90 on heparin. Argatroban
is ordered. Which "A" level safety checks are required before starting? (Select all)
A) Verify aPTT <60 sec off heparin
B) Ensure total bilirubin <3 mg/dL
C) Obtain baseline INR
D) Check hepatic panel because argatroban is hepatically cleared
E) Stop all LMWH flushes
, [Q6] Tier1/MC. A patient with heart failure (EF 20%) is on Entresto (sacubitril/valsartan)
and reports persistent cough. Which action shows "A" level differentiation?
A) Switch to ACE-I
B) Hold Entresto and start ARB alone
C) Explain that valsartan rarely causes cough and assess for pulmonary edema
D) Order chest X-ray to rule out pneumonia
[Q7] Tier1/SATA. During moderate sedation with propofol, the patient’s EtCO2 waveform
suddenly loses plateau and becomes low amplitude. Which "A" level responses are
appropriate? (Select all)
A) Increase propofol to deepen sedation
B) Check airway patency
C) Apply jaw thrust
D) Prepare for insertion of LMA
E) Increase oxygen flow
[Q8] Tier1/MC. A patient with Crohn’s on infliximab has LFTs 3× ULN. Which monitoring
plan reflects "A" level foresight?
A) Stop infliximab permanently
B) Continue and recheck LFTs monthly
C) Hold dose, obtain hepatitis panel and TB gold, recheck in 2 weeks
D) Reduce dose by 50%
