NUR3225 NURSING CARE OF THE
ADULT I
MIDTERM EXAM
2026
A 58-year-old male is admitted to the cardiac telemetry unit following a witnessed
syncopal episode. The 12-lead ECG reveals ST-segment elevation greater than 1 mm in
leads II, III, and aVF, with reciprocal ST depression in leads I and aVL. His troponin I is 4.8
ng/mL (normal less than 0.04 ng/mL), BP is 88/54 mmHg, HR is 42 bpm, and he is
diaphoretic and confused. Which coronary artery is most likely occluded, what
complication does the hemodynamic profile suggest, and what is the nurse's most
critical initial intervention?
A) Left anterior descending artery; cardiogenic shock; initiate dopamine infusion at 20
mcg/kg/min immediately B) Right coronary artery; right ventricular infarction with cardiogenic
shock; establish large-bore IV access, notify the provider and activate the cardiac
catheterization team, place the patient supine, and avoid nitrates and aggressive diuresis C)
Left circumflex artery; hypovolemic shock from acute pericardial effusion; administer 500 mL
normal saline bolus and prepare for pericardiocentesis D) Right coronary artery; neurogenic
shock from vagal activation; administer atropine 1 mg IV push and prepare for transcutaneous
pacing only
Correct Answer: B
Rationale: ST-segment elevation in leads II, III, and aVF with reciprocal changes in I and aVL
localizes the infarction to the inferior wall of the left ventricle, which is supplied by the right
coronary artery (RCA) in approximately 80% of people (right-dominant circulation). The RCA
also supplies the right ventricle via the right marginal branch, making right ventricular infarction
(RVI) a critical complication of inferior STEMI. The hemodynamic triad of RVI includes
hypotension, bradycardia, and clear lung fields (as opposed to left-sided failure which produces
pulmonary congestion). Because the failing right ventricle depends on adequate preload
(venous return) to maintain output, nitrates and diuretics are absolutely contraindicated as they
reduce preload and can precipitate cardiovascular collapse. Volume loading with IV crystalloid
(under careful monitoring) is often required. Activating the cardiac catheterization lab for
emergent PCI is the definitive intervention. Right-sided ECG leads (V3R, V4R) should be
obtained to confirm RVI (ST elevation greater than 1 mm in V4R is diagnostic). UCF nursing
students must associate inferior STEMI with RCA occlusion and the RVI complication to provide
accurate, life-saving care.
A 71-year-old female with a history of chronic heart failure (EF 25%) is admitted with
progressive dyspnea, orthopnea requiring four pillows, bilateral crackles to the mid-lung
fields, JVP elevated at 16 cm, and bilateral pitting edema rated 3+. Her weight today is 8
lbs greater than her dry weight documented one week ago. She is prescribed furosemide
80 mg IV twice daily. Four hours after the first dose, her urine output is 1,850 mL. Her
repeat serum potassium is 3.2 mEq/L and serum sodium is 131 mEq/L. Which nursing
action is most appropriate at this time?
A) Administer the second scheduled dose of furosemide as ordered, since the patient has
significant volume overload requiring aggressive diuresis B) Hold the furosemide dose, notify
the provider of the hypokalemia (3.2 mEq/L) and hyponatremia (131 mEq/L), obtain a 12-lead
ECG to assess for hypokalemia-induced dysrhythmias, and anticipate orders for potassium
,replacement before resuming diuresis C) Administer an oral potassium supplement and proceed
with the furosemide dose as scheduled since the potassium is only mildly low D) Decrease the
furosemide dose to 40 mg IV and continue diuresis without reporting the electrolyte
abnormalities since mild hypokalemia is expected with loop diuretics
Correct Answer: B
Rationale: Loop diuretics (furosemide, bumetanide, torsemide) act on the thick ascending limb
of the loop of Henle by inhibiting the Na-K-2Cl cotransporter, producing potent diuresis with
significant renal losses of potassium, magnesium, sodium, and chloride. A serum potassium of
3.2 mEq/L represents clinically significant hypokalemia (normal 3.5 to 5.0 mEq/L) that requires
correction before additional loop diuretic doses are administered. Hypokalemia sensitizes the
myocardium to dysrhythmias, particularly in a patient with severely reduced cardiac function (EF
25%) who is likely on digoxin or antiarrhythmic agents. Hyponatremia (131 mEq/L) further
indicates electrolyte depletion from aggressive diuresis and may reflect dilutional or depletional
pathology requiring careful evaluation. A 12-lead ECG is indicated to assess for hypokalemia-
associated changes (flattened T waves, prominent U waves, ST depression, prolonged QU
interval). The nurse must hold the dose, communicate the laboratory findings with clinical
context to the provider, and await potassium replacement orders and electrolyte reassessment
before proceeding with further diuresis.
A nurse is caring for a 64-year-old male on mechanical ventilation in the ICU following
emergency repair of a ruptured abdominal aortic aneurysm. On postoperative day 2, the
patient develops sudden fever of 39.4°C, new-onset confusion as sedation is weaned,
and his endotracheal tube secretions become purulent yellow-green. His chest X-ray
shows a new right lower lobe infiltrate. He has been on the ventilator for 52 hours. The
provider suspects ventilator-associated pneumonia (VAP). Which bundle of evidence-
based nursing interventions is specifically designed to prevent VAP, and which
component directly addresses the aspiration of contaminated oropharyngeal secretions?
A) Foley catheter care bundle; chlorhexidine-impregnated urinary catheters reduce bacterial
colonization of the respiratory tract B) Ventilator-associated pneumonia (VAP) bundle: head of
bed elevation to 30 to 45 degrees, daily sedation interruption and readiness to extubate
assessment, peptic ulcer prophylaxis, DVT prophylaxis, and oral care with chlorhexidine 0.12%;
head of bed elevation at 30 to 45 degrees most directly prevents aspiration C) CLABSI
prevention bundle; daily assessment of central line necessity prevents bacterial seeding of the
lungs D) CAUTI prevention bundle; reducing urinary tract infections decreases systemic
bacterial load available for hematogenous pulmonary seeding
Correct Answer: B
Rationale: Ventilator-associated pneumonia develops primarily through microaspiration of
colonized oropharyngeal secretions past the endotracheal tube cuff into the lower respiratory
tract. The Institute for Healthcare Improvement (IHI) VAP bundle addresses multiple pathways:
(1) Head of bed elevation to 30 to 45 degrees uses gravity to reduce gastric content reflux and
oropharyngeal secretion aspiration into the lungs, the most directly preventive component for
aspiration. (2) Daily sedation vacation and spontaneous breathing trials reduce total ventilation
duration, the strongest predictor of VAP risk. (3) Oral care with 0.12% chlorhexidine gluconate
reduces oropharyngeal bacterial colonization by up to 50%, decreasing the pathogen burden
available for aspiration. (4) Peptic ulcer prophylaxis reduces stress ulceration and GI bleeding
risk. (5) DVT prophylaxis prevents thromboembolic complications in immobile ventilated
patients. Bundle compliance is monitored as an all-or-nothing measure. UCF nursing students
rotating through ICU settings are expected to articulate each bundle component and its specific
mechanism of VAP prevention. VAP develops after 48 hours of mechanical ventilation,
distinguishing it from hospital-acquired pneumonia.
A 49-year-old female with a 10-year history of systemic lupus erythematosus (SLE) is
admitted with a serum creatinine of 3.8 mg/dL (baseline 1.1 mg/dL three months ago),
urine protein-to-creatinine ratio of 4.2 g/g, RBC casts on urinalysis, hematuria, and blood
pressure of 168/104 mmHg. She reports decreased urine output and bilateral ankle
,edema over the past two weeks. Which clinical syndrome does this constellation of
findings represent, and what is the most important nursing priority in managing her fluid
balance?
A) Nephrotic syndrome; administer albumin infusions to restore oncotic pressure and reduce
proteinuria B) Lupus nephritis presenting as nephritic syndrome with rapidly progressive
glomerulonephritis; strict intake and output measurement, daily weights, fluid restriction per
provider order, and antihypertensive management to slow further renal injury C) Acute tubular
necrosis from NSAID use; aggressive IV fluid resuscitation with normal saline to restore tubular
perfusion D) Urinary tract infection causing obstructive uropathy; catheter placement to relieve
obstruction and obtain urine culture
Correct Answer: B
Rationale: This presentation is classic for lupus nephritis with nephritic syndrome: acute decline
in renal function (creatinine rising from 1.1 to 3.8 mg/dL indicates greater than 50% reduction in
GFR), hematuria with RBC casts (pathognomonic for glomerular inflammation and bleeding),
significant proteinuria (4.2 g/g), hypertension, and edema. RBC casts are considered the
hallmark of glomerulonephritis because they form only within the renal tubules from RBCs that
have passed through damaged glomerular capillaries. Lupus nephritis occurs in 40 to 60% of
SLE patients and represents the leading cause of morbidity and mortality. The rate of creatinine
rise over 3 months suggests rapidly progressive glomerulonephritis, a nephrology emergency.
Nursing priorities include: accurate intake and output documentation (essential for guiding fluid
management in oliguric renal failure), daily weights (each kilogram represents approximately
one liter of fluid), fluid restriction and dietary sodium restriction per nephrology orders, blood
pressure management (ACE inhibitors/ARBs are preferred for renoprotection), and preparation
for renal biopsy to classify the specific WHO class of lupus nephritis guiding
immunosuppressive therapy. Aggressive IV fluids would worsen volume overload in a patient
with oliguric glomerulonephritis.
A 23-year-old male college student is brought to the emergency department by friends
after being found unresponsive at a party. His GCS is 9 (E2V3M4). His friends report he
consumed a large quantity of alcohol and possibly other substances. On assessment,
the nurse notes diaphoresis, a respiratory rate of 8 breaths per minute, pinpoint pupils,
and pulse oximetry of 89% on room air. His temperature is 35.8°C. Naloxone 0.4 mg is
administered IV with partial improvement in respiratory rate to 12 breaths per minute but
pupils remain constricted and he remains obtunded. Which interpretation of the partial
naloxone response is most clinically accurate, and what is the nurse's most important
next action?
A) The partial response confirms pure alcohol intoxication; administer thiamine 100 mg IV and
glucose 50 mL of D50W B) The partial response suggests co-ingestion of opioids with another
CNS depressant (likely alcohol or benzodiazepines); the opioid effect was partially reversed but
the co-ingestion continues to depress the CNS; administer additional naloxone per protocol
(repeat doses or infusion), ensure airway management readiness including preparation for
intubation, and obtain a comprehensive toxicology screen C) The partial response confirms the
patient is no longer at risk and naloxone can be discontinued since the respiratory rate improved
D) The partial response indicates the patient has opioid tolerance and a higher naloxone dose
of 10 mg should be administered immediately
Correct Answer: B
Rationale: Pinpoint pupils (miosis) and respiratory depression with partial response to naloxone
are consistent with opioid toxicity with co-ingestion. Alcohol and opioids produce synergistic
CNS and respiratory depression through complementary mechanisms (GABA enhancement by
alcohol; mu-receptor agonism by opioids), both converging on brainstem respiratory centers.
The partial naloxone response indicates sufficient opioid receptor occupancy to produce partial
reversal, while the remaining CNS depression (obtundation, bradypnea) is maintained by the
non-opioid co-ingestion (alcohol or benzodiazepines) that naloxone cannot reverse. Critically,
naloxone has a shorter half-life (30 to 90 minutes) than most opioids; as the naloxone effect
wanes, full re-narcotization can occur rapidly. The nurse must anticipate the need for repeated
, doses (0.4 mg every 2 to 3 minutes) or a naloxone infusion (two-thirds of the effective bolus
dose per hour). Airway management readiness is the highest priority because respiratory
depression with SpO2 89% indicates impending respiratory failure. Fentanyl test strips and
comprehensive urine toxicology panels should be obtained. This scenario reflects the clinical
reality of polysubstance overdose increasingly encountered in young adult patients at UCF-
affiliated emergency departments.
A 77-year-old female with known aortic stenosis is scheduled for elective laparoscopic
cholecystectomy. During the preoperative assessment, her echocardiogram shows a
valve area of 0.7 cm² and a mean gradient of 55 mmHg. Her current vital signs are BP
102/64 mmHg, HR 88 bpm regular, and she reports dyspnea on minimal exertion,
occasional syncopal episodes, and exertional chest discomfort. Which classification of
aortic stenosis severity does this represent, what is the clinical significance of her
symptom triad, and what preoperative concern must the nurse immediately communicate
to the surgical team?
A) Moderate aortic stenosis; symptoms are unrelated to valve disease; routine preoperative
clearance is appropriate B) Severe aortic stenosis (valve area less than 1.0 cm², mean gradient
greater than 40 mmHg); the classic symptom triad of angina, syncope, and heart failure
(dyspnea) indicates significantly increased mortality risk with non-cardiac surgery; the nurse
must immediately communicate these findings to the surgical and anesthesia team for urgent
cardiology evaluation and potential valve intervention before elective surgery C) Critical aortic
stenosis requiring emergent surgical valve replacement before any elective procedures; the
nurse should cancel the cholecystectomy and schedule emergency cardiac surgery D) Mild
aortic stenosis; the symptoms are likely due to deconditioning in an elderly patient; preoperative
cardiology consultation is optional
Correct Answer: B
Rationale: Severe aortic stenosis is defined by echocardiographic criteria including valve area
less than 1.0 cm² (critical less than 0.6 cm²), mean gradient greater than 40 mmHg, and peak jet
velocity greater than 4 m/sec. This patient's valve area of 0.7 cm² and mean gradient of 55
mmHg confirm severe AS. The classic triad of aortic stenosis symptoms carries well-established
prognostic significance: (1) Angina: 50% five-year survival without intervention. (2) Syncope:
50% three-year survival. (3) Heart failure (dyspnea): 50% two-year survival. Critically, the
presence of any symptomatic severe AS dramatically increases perioperative mortality with non-
cardiac surgery due to the fixed cardiac output state created by the obstruction; these patients
cannot compensate for anesthetic-induced vasodilation, bleeding, or tachycardia. Elective non-
cardiac surgery should be postponed until cardiology evaluation and potential transcatheter
aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) is completed. The
nurse plays the essential role of recognizing these findings and escalating communication to the
surgical team before a preventable perioperative catastrophe occurs.
A 55-year-old male with alcohol use disorder is admitted for management of acute
alcohol withdrawal. His last drink was approximately 18 hours ago. He is tremulous,
anxious, diaphoretic, tachycardic at 118 bpm, hypertensive at 158/96 mmHg, and
hyperreflexic. His CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol) score
is 22. Which pharmacological class is the first-line treatment for alcohol withdrawal, and
which specific complication, if untreated, carries the highest mortality risk in this
patient?
A) Antipsychotics (haloperidol); the greatest risk is alcohol-induced psychosis progressing to
violence B) Opioid analgesics (morphine); the greatest risk is pain crisis from autonomic
hyperactivation causing myocardial infarction C) Benzodiazepines (diazepam, lorazepam, or
chlordiazepoxide); the greatest risk is generalized tonic-clonic seizures progressing to status
epilepticus, and delirium tremens (DTs), which carries a mortality rate of up to 5 to 10% if
untreated D) Beta-blockers (propranolol); the greatest risk is hypertensive emergency causing
hemorrhagic stroke
Correct Answer: C
ADULT I
MIDTERM EXAM
2026
A 58-year-old male is admitted to the cardiac telemetry unit following a witnessed
syncopal episode. The 12-lead ECG reveals ST-segment elevation greater than 1 mm in
leads II, III, and aVF, with reciprocal ST depression in leads I and aVL. His troponin I is 4.8
ng/mL (normal less than 0.04 ng/mL), BP is 88/54 mmHg, HR is 42 bpm, and he is
diaphoretic and confused. Which coronary artery is most likely occluded, what
complication does the hemodynamic profile suggest, and what is the nurse's most
critical initial intervention?
A) Left anterior descending artery; cardiogenic shock; initiate dopamine infusion at 20
mcg/kg/min immediately B) Right coronary artery; right ventricular infarction with cardiogenic
shock; establish large-bore IV access, notify the provider and activate the cardiac
catheterization team, place the patient supine, and avoid nitrates and aggressive diuresis C)
Left circumflex artery; hypovolemic shock from acute pericardial effusion; administer 500 mL
normal saline bolus and prepare for pericardiocentesis D) Right coronary artery; neurogenic
shock from vagal activation; administer atropine 1 mg IV push and prepare for transcutaneous
pacing only
Correct Answer: B
Rationale: ST-segment elevation in leads II, III, and aVF with reciprocal changes in I and aVL
localizes the infarction to the inferior wall of the left ventricle, which is supplied by the right
coronary artery (RCA) in approximately 80% of people (right-dominant circulation). The RCA
also supplies the right ventricle via the right marginal branch, making right ventricular infarction
(RVI) a critical complication of inferior STEMI. The hemodynamic triad of RVI includes
hypotension, bradycardia, and clear lung fields (as opposed to left-sided failure which produces
pulmonary congestion). Because the failing right ventricle depends on adequate preload
(venous return) to maintain output, nitrates and diuretics are absolutely contraindicated as they
reduce preload and can precipitate cardiovascular collapse. Volume loading with IV crystalloid
(under careful monitoring) is often required. Activating the cardiac catheterization lab for
emergent PCI is the definitive intervention. Right-sided ECG leads (V3R, V4R) should be
obtained to confirm RVI (ST elevation greater than 1 mm in V4R is diagnostic). UCF nursing
students must associate inferior STEMI with RCA occlusion and the RVI complication to provide
accurate, life-saving care.
A 71-year-old female with a history of chronic heart failure (EF 25%) is admitted with
progressive dyspnea, orthopnea requiring four pillows, bilateral crackles to the mid-lung
fields, JVP elevated at 16 cm, and bilateral pitting edema rated 3+. Her weight today is 8
lbs greater than her dry weight documented one week ago. She is prescribed furosemide
80 mg IV twice daily. Four hours after the first dose, her urine output is 1,850 mL. Her
repeat serum potassium is 3.2 mEq/L and serum sodium is 131 mEq/L. Which nursing
action is most appropriate at this time?
A) Administer the second scheduled dose of furosemide as ordered, since the patient has
significant volume overload requiring aggressive diuresis B) Hold the furosemide dose, notify
the provider of the hypokalemia (3.2 mEq/L) and hyponatremia (131 mEq/L), obtain a 12-lead
ECG to assess for hypokalemia-induced dysrhythmias, and anticipate orders for potassium
,replacement before resuming diuresis C) Administer an oral potassium supplement and proceed
with the furosemide dose as scheduled since the potassium is only mildly low D) Decrease the
furosemide dose to 40 mg IV and continue diuresis without reporting the electrolyte
abnormalities since mild hypokalemia is expected with loop diuretics
Correct Answer: B
Rationale: Loop diuretics (furosemide, bumetanide, torsemide) act on the thick ascending limb
of the loop of Henle by inhibiting the Na-K-2Cl cotransporter, producing potent diuresis with
significant renal losses of potassium, magnesium, sodium, and chloride. A serum potassium of
3.2 mEq/L represents clinically significant hypokalemia (normal 3.5 to 5.0 mEq/L) that requires
correction before additional loop diuretic doses are administered. Hypokalemia sensitizes the
myocardium to dysrhythmias, particularly in a patient with severely reduced cardiac function (EF
25%) who is likely on digoxin or antiarrhythmic agents. Hyponatremia (131 mEq/L) further
indicates electrolyte depletion from aggressive diuresis and may reflect dilutional or depletional
pathology requiring careful evaluation. A 12-lead ECG is indicated to assess for hypokalemia-
associated changes (flattened T waves, prominent U waves, ST depression, prolonged QU
interval). The nurse must hold the dose, communicate the laboratory findings with clinical
context to the provider, and await potassium replacement orders and electrolyte reassessment
before proceeding with further diuresis.
A nurse is caring for a 64-year-old male on mechanical ventilation in the ICU following
emergency repair of a ruptured abdominal aortic aneurysm. On postoperative day 2, the
patient develops sudden fever of 39.4°C, new-onset confusion as sedation is weaned,
and his endotracheal tube secretions become purulent yellow-green. His chest X-ray
shows a new right lower lobe infiltrate. He has been on the ventilator for 52 hours. The
provider suspects ventilator-associated pneumonia (VAP). Which bundle of evidence-
based nursing interventions is specifically designed to prevent VAP, and which
component directly addresses the aspiration of contaminated oropharyngeal secretions?
A) Foley catheter care bundle; chlorhexidine-impregnated urinary catheters reduce bacterial
colonization of the respiratory tract B) Ventilator-associated pneumonia (VAP) bundle: head of
bed elevation to 30 to 45 degrees, daily sedation interruption and readiness to extubate
assessment, peptic ulcer prophylaxis, DVT prophylaxis, and oral care with chlorhexidine 0.12%;
head of bed elevation at 30 to 45 degrees most directly prevents aspiration C) CLABSI
prevention bundle; daily assessment of central line necessity prevents bacterial seeding of the
lungs D) CAUTI prevention bundle; reducing urinary tract infections decreases systemic
bacterial load available for hematogenous pulmonary seeding
Correct Answer: B
Rationale: Ventilator-associated pneumonia develops primarily through microaspiration of
colonized oropharyngeal secretions past the endotracheal tube cuff into the lower respiratory
tract. The Institute for Healthcare Improvement (IHI) VAP bundle addresses multiple pathways:
(1) Head of bed elevation to 30 to 45 degrees uses gravity to reduce gastric content reflux and
oropharyngeal secretion aspiration into the lungs, the most directly preventive component for
aspiration. (2) Daily sedation vacation and spontaneous breathing trials reduce total ventilation
duration, the strongest predictor of VAP risk. (3) Oral care with 0.12% chlorhexidine gluconate
reduces oropharyngeal bacterial colonization by up to 50%, decreasing the pathogen burden
available for aspiration. (4) Peptic ulcer prophylaxis reduces stress ulceration and GI bleeding
risk. (5) DVT prophylaxis prevents thromboembolic complications in immobile ventilated
patients. Bundle compliance is monitored as an all-or-nothing measure. UCF nursing students
rotating through ICU settings are expected to articulate each bundle component and its specific
mechanism of VAP prevention. VAP develops after 48 hours of mechanical ventilation,
distinguishing it from hospital-acquired pneumonia.
A 49-year-old female with a 10-year history of systemic lupus erythematosus (SLE) is
admitted with a serum creatinine of 3.8 mg/dL (baseline 1.1 mg/dL three months ago),
urine protein-to-creatinine ratio of 4.2 g/g, RBC casts on urinalysis, hematuria, and blood
pressure of 168/104 mmHg. She reports decreased urine output and bilateral ankle
,edema over the past two weeks. Which clinical syndrome does this constellation of
findings represent, and what is the most important nursing priority in managing her fluid
balance?
A) Nephrotic syndrome; administer albumin infusions to restore oncotic pressure and reduce
proteinuria B) Lupus nephritis presenting as nephritic syndrome with rapidly progressive
glomerulonephritis; strict intake and output measurement, daily weights, fluid restriction per
provider order, and antihypertensive management to slow further renal injury C) Acute tubular
necrosis from NSAID use; aggressive IV fluid resuscitation with normal saline to restore tubular
perfusion D) Urinary tract infection causing obstructive uropathy; catheter placement to relieve
obstruction and obtain urine culture
Correct Answer: B
Rationale: This presentation is classic for lupus nephritis with nephritic syndrome: acute decline
in renal function (creatinine rising from 1.1 to 3.8 mg/dL indicates greater than 50% reduction in
GFR), hematuria with RBC casts (pathognomonic for glomerular inflammation and bleeding),
significant proteinuria (4.2 g/g), hypertension, and edema. RBC casts are considered the
hallmark of glomerulonephritis because they form only within the renal tubules from RBCs that
have passed through damaged glomerular capillaries. Lupus nephritis occurs in 40 to 60% of
SLE patients and represents the leading cause of morbidity and mortality. The rate of creatinine
rise over 3 months suggests rapidly progressive glomerulonephritis, a nephrology emergency.
Nursing priorities include: accurate intake and output documentation (essential for guiding fluid
management in oliguric renal failure), daily weights (each kilogram represents approximately
one liter of fluid), fluid restriction and dietary sodium restriction per nephrology orders, blood
pressure management (ACE inhibitors/ARBs are preferred for renoprotection), and preparation
for renal biopsy to classify the specific WHO class of lupus nephritis guiding
immunosuppressive therapy. Aggressive IV fluids would worsen volume overload in a patient
with oliguric glomerulonephritis.
A 23-year-old male college student is brought to the emergency department by friends
after being found unresponsive at a party. His GCS is 9 (E2V3M4). His friends report he
consumed a large quantity of alcohol and possibly other substances. On assessment,
the nurse notes diaphoresis, a respiratory rate of 8 breaths per minute, pinpoint pupils,
and pulse oximetry of 89% on room air. His temperature is 35.8°C. Naloxone 0.4 mg is
administered IV with partial improvement in respiratory rate to 12 breaths per minute but
pupils remain constricted and he remains obtunded. Which interpretation of the partial
naloxone response is most clinically accurate, and what is the nurse's most important
next action?
A) The partial response confirms pure alcohol intoxication; administer thiamine 100 mg IV and
glucose 50 mL of D50W B) The partial response suggests co-ingestion of opioids with another
CNS depressant (likely alcohol or benzodiazepines); the opioid effect was partially reversed but
the co-ingestion continues to depress the CNS; administer additional naloxone per protocol
(repeat doses or infusion), ensure airway management readiness including preparation for
intubation, and obtain a comprehensive toxicology screen C) The partial response confirms the
patient is no longer at risk and naloxone can be discontinued since the respiratory rate improved
D) The partial response indicates the patient has opioid tolerance and a higher naloxone dose
of 10 mg should be administered immediately
Correct Answer: B
Rationale: Pinpoint pupils (miosis) and respiratory depression with partial response to naloxone
are consistent with opioid toxicity with co-ingestion. Alcohol and opioids produce synergistic
CNS and respiratory depression through complementary mechanisms (GABA enhancement by
alcohol; mu-receptor agonism by opioids), both converging on brainstem respiratory centers.
The partial naloxone response indicates sufficient opioid receptor occupancy to produce partial
reversal, while the remaining CNS depression (obtundation, bradypnea) is maintained by the
non-opioid co-ingestion (alcohol or benzodiazepines) that naloxone cannot reverse. Critically,
naloxone has a shorter half-life (30 to 90 minutes) than most opioids; as the naloxone effect
wanes, full re-narcotization can occur rapidly. The nurse must anticipate the need for repeated
, doses (0.4 mg every 2 to 3 minutes) or a naloxone infusion (two-thirds of the effective bolus
dose per hour). Airway management readiness is the highest priority because respiratory
depression with SpO2 89% indicates impending respiratory failure. Fentanyl test strips and
comprehensive urine toxicology panels should be obtained. This scenario reflects the clinical
reality of polysubstance overdose increasingly encountered in young adult patients at UCF-
affiliated emergency departments.
A 77-year-old female with known aortic stenosis is scheduled for elective laparoscopic
cholecystectomy. During the preoperative assessment, her echocardiogram shows a
valve area of 0.7 cm² and a mean gradient of 55 mmHg. Her current vital signs are BP
102/64 mmHg, HR 88 bpm regular, and she reports dyspnea on minimal exertion,
occasional syncopal episodes, and exertional chest discomfort. Which classification of
aortic stenosis severity does this represent, what is the clinical significance of her
symptom triad, and what preoperative concern must the nurse immediately communicate
to the surgical team?
A) Moderate aortic stenosis; symptoms are unrelated to valve disease; routine preoperative
clearance is appropriate B) Severe aortic stenosis (valve area less than 1.0 cm², mean gradient
greater than 40 mmHg); the classic symptom triad of angina, syncope, and heart failure
(dyspnea) indicates significantly increased mortality risk with non-cardiac surgery; the nurse
must immediately communicate these findings to the surgical and anesthesia team for urgent
cardiology evaluation and potential valve intervention before elective surgery C) Critical aortic
stenosis requiring emergent surgical valve replacement before any elective procedures; the
nurse should cancel the cholecystectomy and schedule emergency cardiac surgery D) Mild
aortic stenosis; the symptoms are likely due to deconditioning in an elderly patient; preoperative
cardiology consultation is optional
Correct Answer: B
Rationale: Severe aortic stenosis is defined by echocardiographic criteria including valve area
less than 1.0 cm² (critical less than 0.6 cm²), mean gradient greater than 40 mmHg, and peak jet
velocity greater than 4 m/sec. This patient's valve area of 0.7 cm² and mean gradient of 55
mmHg confirm severe AS. The classic triad of aortic stenosis symptoms carries well-established
prognostic significance: (1) Angina: 50% five-year survival without intervention. (2) Syncope:
50% three-year survival. (3) Heart failure (dyspnea): 50% two-year survival. Critically, the
presence of any symptomatic severe AS dramatically increases perioperative mortality with non-
cardiac surgery due to the fixed cardiac output state created by the obstruction; these patients
cannot compensate for anesthetic-induced vasodilation, bleeding, or tachycardia. Elective non-
cardiac surgery should be postponed until cardiology evaluation and potential transcatheter
aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) is completed. The
nurse plays the essential role of recognizing these findings and escalating communication to the
surgical team before a preventable perioperative catastrophe occurs.
A 55-year-old male with alcohol use disorder is admitted for management of acute
alcohol withdrawal. His last drink was approximately 18 hours ago. He is tremulous,
anxious, diaphoretic, tachycardic at 118 bpm, hypertensive at 158/96 mmHg, and
hyperreflexic. His CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol) score
is 22. Which pharmacological class is the first-line treatment for alcohol withdrawal, and
which specific complication, if untreated, carries the highest mortality risk in this
patient?
A) Antipsychotics (haloperidol); the greatest risk is alcohol-induced psychosis progressing to
violence B) Opioid analgesics (morphine); the greatest risk is pain crisis from autonomic
hyperactivation causing myocardial infarction C) Benzodiazepines (diazepam, lorazepam, or
chlordiazepoxide); the greatest risk is generalized tonic-clonic seizures progressing to status
epilepticus, and delirium tremens (DTs), which carries a mortality rate of up to 5 to 10% if
untreated D) Beta-blockers (propranolol); the greatest risk is hypertensive emergency causing
hemorrhagic stroke
Correct Answer: C
