NSG430 Adult Health Nursing II Exam 2
Comprehensive Review | Acute & Complex Care
Management | 2026/2027 New Edition
Section 1: Cardiovascular Nursing
Q1: A client is 24 hours post-MI and is receiving a heparin infusion. The nurse assesses
the client and notes bleeding gums, hematuria, and a large hematoma at the IV site. The
client's aPTT is 110 seconds. What is the nurse's priority action?
A) Administer the prescribed protamine sulfate immediately.
B) Stop the heparin infusion and notify the provider stat.
C) Draw a stat hemoglobin and hematocrit level.
D) Apply direct pressure to the IV site and reassess in 15 minutes.
Correct Answer: B
Rationale: The client is showing signs of active bleeding and has a critically elevated
aPTT, indicating heparin overdose/toxicity. The immediate life-threatening priority is to
stop the source of the anticoagulation (the infusion) and alert the provider for further
orders, which may include protamine sulfate (A). While drawing labs (C) and applying
pressure (D) are appropriate concurrent actions, they do not address the root cause of
the bleeding and are secondary to stopping the infusion.
,Q2: A client with heart failure is prescribed furosemide 80 mg IV push twice daily. Which
assessment finding requires immediate intervention by the nurse?
A) Weight gain of 0.5 kg in 24 hours
B) Serum potassium level of 3.2 mEq/L
C) Urine output of 1500 mL over 8 hours
D) Bibasilar crackles on auscultation
Correct Answer: B
Rationale: Furosemide is a loop diuretic that causes potassium loss. A serum
potassium of 3.2 mEq/L is below the normal range (3.5–5.0 mEq/L) and places the
client at high risk for life-threatening dysrhythmias. Immediate intervention includes
withholding the dose and notifying the provider. Weight gain (A) and crackles (D)
indicate fluid overload but are not immediately life-threatening. High urine output (C) is
an expected diuretic effect.
Q3: The nurse is monitoring a client with atrial fibrillation who is receiving diltiazem. The
client’s heart rate is 48 beats/min and blood pressure is 88/50 mm Hg. What is the
nurse’s best action?
A) Continue the infusion and recheck in 15 minutes
B) Stop the infusion and administer a 500 mL normal saline bolus
C) Stop the infusion and notify the provider
D) Increase the infusion rate to maintain cardiac output
Correct Answer: C
,Rationale: Diltiazem is a calcium channel blocker that can cause bradycardia and
hypotension. A heart rate <50 and systolic BP <90 are clear signs of medication toxicity.
The infusion must be discontinued immediately and the provider notified for possible
antidote or supportive care. Continuing (A) or increasing (D) the infusion would worsen
toxicity. A saline bolus (B) is not indicated without provider orders and does not address
the underlying drug effect.
Q4: A client is admitted with acute decompensated heart failure (ADHF). Which order
should the nurse implement first?
A) Initiate high-flow oxygen via non-rebreather
B) Administer IV morphine sulfate 2 mg
C) Insert a Foley catheter
D) Obtain a stat chest X-ray
Correct Answer: A
Rationale: ADHF causes pulmonary edema and impaired oxygenation. High-flow oxygen
is the only intervention that directly addresses the immediate threat to life—hypoxemia.
Morphine (B) reduces anxiety and preload but is no longer first-line. A Foley (C) and
chest X-ray (D) are important but not priority over oxygenation.
Q5: [SATA] The nurse is caring for a client receiving tissue plasminogen activator (tPA)
for an acute ischemic stroke. Which assessments are essential during the infusion?
(Select all that apply.)
A) Neurological checks every 15 minutes
, B) Blood pressure every 15 minutes
C) Signs of bleeding from any site
D) Heart rate every 4 hours
E) Temperature every 8 hours
F) Serum fibrinogen level every 6 hours
Correct Answers: A, B, C
Rationale: tPA carries a high risk of intracranial hemorrhage. Neurological deterioration
(A) or uncontrolled bleeding (C) must be detected immediately. BP must be kept
<185/110 mm Hg to reduce hemorrhage risk, so q15-min monitoring (B) is required.
Heart rate (D) and temperature (E) are standard but not tPA-specific. Fibrinogen (F) is
monitored for other fibrinolytics, not tPA.
Q6: [Ordered Response] Sequence the nurse’s actions when preparing to administer a
unit of packed red blood cells (PRBCs).
1. Obtain baseline vital signs
2. Verify blood product with another RN at bedside
3. Prime Y-type blood tubing with 0.9% normal saline
4. Start infusion slowly (2 mL/min) for first 15 minutes
5. Stay with client for first 15 minutes
Correct Order: 1 → 3 → 2 → 4 → 5
Rationale: Baseline vitals (1) are required to detect transfusion reactions. Tubing must
be saline-primed (3) to prevent hemolysis. Dual verification (2) ensures right
product/right patient. Slow start (4) and direct observation (5) allow early detection of
acute hemolytic or allergic reactions.
Comprehensive Review | Acute & Complex Care
Management | 2026/2027 New Edition
Section 1: Cardiovascular Nursing
Q1: A client is 24 hours post-MI and is receiving a heparin infusion. The nurse assesses
the client and notes bleeding gums, hematuria, and a large hematoma at the IV site. The
client's aPTT is 110 seconds. What is the nurse's priority action?
A) Administer the prescribed protamine sulfate immediately.
B) Stop the heparin infusion and notify the provider stat.
C) Draw a stat hemoglobin and hematocrit level.
D) Apply direct pressure to the IV site and reassess in 15 minutes.
Correct Answer: B
Rationale: The client is showing signs of active bleeding and has a critically elevated
aPTT, indicating heparin overdose/toxicity. The immediate life-threatening priority is to
stop the source of the anticoagulation (the infusion) and alert the provider for further
orders, which may include protamine sulfate (A). While drawing labs (C) and applying
pressure (D) are appropriate concurrent actions, they do not address the root cause of
the bleeding and are secondary to stopping the infusion.
,Q2: A client with heart failure is prescribed furosemide 80 mg IV push twice daily. Which
assessment finding requires immediate intervention by the nurse?
A) Weight gain of 0.5 kg in 24 hours
B) Serum potassium level of 3.2 mEq/L
C) Urine output of 1500 mL over 8 hours
D) Bibasilar crackles on auscultation
Correct Answer: B
Rationale: Furosemide is a loop diuretic that causes potassium loss. A serum
potassium of 3.2 mEq/L is below the normal range (3.5–5.0 mEq/L) and places the
client at high risk for life-threatening dysrhythmias. Immediate intervention includes
withholding the dose and notifying the provider. Weight gain (A) and crackles (D)
indicate fluid overload but are not immediately life-threatening. High urine output (C) is
an expected diuretic effect.
Q3: The nurse is monitoring a client with atrial fibrillation who is receiving diltiazem. The
client’s heart rate is 48 beats/min and blood pressure is 88/50 mm Hg. What is the
nurse’s best action?
A) Continue the infusion and recheck in 15 minutes
B) Stop the infusion and administer a 500 mL normal saline bolus
C) Stop the infusion and notify the provider
D) Increase the infusion rate to maintain cardiac output
Correct Answer: C
,Rationale: Diltiazem is a calcium channel blocker that can cause bradycardia and
hypotension. A heart rate <50 and systolic BP <90 are clear signs of medication toxicity.
The infusion must be discontinued immediately and the provider notified for possible
antidote or supportive care. Continuing (A) or increasing (D) the infusion would worsen
toxicity. A saline bolus (B) is not indicated without provider orders and does not address
the underlying drug effect.
Q4: A client is admitted with acute decompensated heart failure (ADHF). Which order
should the nurse implement first?
A) Initiate high-flow oxygen via non-rebreather
B) Administer IV morphine sulfate 2 mg
C) Insert a Foley catheter
D) Obtain a stat chest X-ray
Correct Answer: A
Rationale: ADHF causes pulmonary edema and impaired oxygenation. High-flow oxygen
is the only intervention that directly addresses the immediate threat to life—hypoxemia.
Morphine (B) reduces anxiety and preload but is no longer first-line. A Foley (C) and
chest X-ray (D) are important but not priority over oxygenation.
Q5: [SATA] The nurse is caring for a client receiving tissue plasminogen activator (tPA)
for an acute ischemic stroke. Which assessments are essential during the infusion?
(Select all that apply.)
A) Neurological checks every 15 minutes
, B) Blood pressure every 15 minutes
C) Signs of bleeding from any site
D) Heart rate every 4 hours
E) Temperature every 8 hours
F) Serum fibrinogen level every 6 hours
Correct Answers: A, B, C
Rationale: tPA carries a high risk of intracranial hemorrhage. Neurological deterioration
(A) or uncontrolled bleeding (C) must be detected immediately. BP must be kept
<185/110 mm Hg to reduce hemorrhage risk, so q15-min monitoring (B) is required.
Heart rate (D) and temperature (E) are standard but not tPA-specific. Fibrinogen (F) is
monitored for other fibrinolytics, not tPA.
Q6: [Ordered Response] Sequence the nurse’s actions when preparing to administer a
unit of packed red blood cells (PRBCs).
1. Obtain baseline vital signs
2. Verify blood product with another RN at bedside
3. Prime Y-type blood tubing with 0.9% normal saline
4. Start infusion slowly (2 mL/min) for first 15 minutes
5. Stay with client for first 15 minutes
Correct Order: 1 → 3 → 2 → 4 → 5
Rationale: Baseline vitals (1) are required to detect transfusion reactions. Tubing must
be saline-primed (3) to prevent hemolysis. Dual verification (2) ensures right
product/right patient. Slow start (4) and direct observation (5) allow early detection of
acute hemolytic or allergic reactions.
