NSG 3850 Advanced Adult Health Nursing –
Comprehensive Final Examination (Academic
Year 2024–2025)
SECTION I: ADVANCED CARDIOVASCULAR NURSING
**Question 1**
A 72-year-old male presents with crushing substernal chest pain radiating to the jaw,
diaphoresis, and nausea. Vital signs reveal a blood pressure of 82/54 mmHg, heart rate
of 110 bpm, and respiratory rate of 24. The 12-lead ECG shows ST-segment elevation
in leads V1-V4 with reciprocal ST depression in leads II, III, and aVF. Which
hemodynamic parameter best differentiates cardiogenic shock from a simple STEMI in
this patient?
☐ A. Systolic blood pressure below 90 mmHg lasting more than 30 minutes with
adequate fluid resuscitation
☑ B. Cardiac index less than 2.2 L/min/m² and pulmonary capillary wedge pressure
greater than 18 mmHg
☐ C. Systemic vascular resistance index below 1500 dynes/sec/cm⁻⁵/m² refractory to
vasopressor therapy
☐ D. Mixed venous oxygen saturation exceeding 75% despite supplemental oxygen
delivery
**Rationale:** Cardiogenic shock is defined by tissue hypoperfusion due to primary
cardiac pump failure. The hemodynamic criteria include a cardiac index (CI) < 2.2
L/min/m² (indicating inadequate perfusion) coupled with elevated pulmonary capillary
wedge pressure (PCWP > 18 mmHg), indicating left ventricular failure and fluid backup
into the pulmonary circulation. While hypotension (Option A) is present, it is not specific
to shock without the perfusion metrics. Option C describes a inappropriate vasodilation
seen in septic shock, not the vasoconstrictive state of cardiogenic shock. Option D
,indicates adequate tissue oxygen extraction, which is contrary to the pathophysiology of
shock where SvO2 is typically low.
**Question 2**
Following an anterior wall myocardial infarction, a patient develops acute mitral
regurgitation due to papillary muscle rupture. Which physical assessment finding would
the nurse anticipate during auscultation?
☐ A. A harsh, crescendo-decrescendo systolic murmur heard best at the right upper
sternal border radiating to the carotids
☑ B. A holosystolic blowing murmur at the apex radiating toward the left axilla
☐ C. A diastolic rumbling murmur with an opening snap heard at the fifth intercostal
space, mid-clavicular line
☐ D. A pericardial friction rub best heard with the patient leaning forward during end-
expiration
**Rationale:** Acute mitral regurgitation from papillary muscle dysfunction or rupture
post-MI produces a holosystolic (pansystolic) murmur best heard at the cardiac apex.
The regurgitant flow directs blood back into the left atrium during systole, creating the
blowing quality and radiation toward the axilla. Option A describes aortic stenosis.
Option C describes mitral stenosis. Option D indicates pericarditis, which may occur as
Dressler’s syndrome but is unrelated to valvular rupture.
**Question 3**
A patient with chronic heart failure is receiving an intravenous infusion of milrinone.
Which assessment finding requires immediate intervention by the registered nurse?
☐ A. Increase in cardiac output from 4 L/min to 6 L/min
☐ B. Potassium level decreasing from 4.2 mEq/L to 3.8 mEq/L
☑ C. Ventricular ectopy increasing to 12 premature ventricular contractions per minute
,☐ D. Mean arterial pressure decreasing from 78 mmHg to 72 mmHg
**Rationale:** Milrinone is a phosphodiesterase-3 inhibitor with both inotropic and
vasodilatory properties. It increases myocardial oxygen consumption and can
precipitate ventricular arrhythmias, including life-threatening ventricular tachycardia. An
increase in ventricular ectopy to trigeminy or higher frequency (Option C) necessitates
immediate assessment, possible discontinuation of the infusion, and notification of the
provider. While Option B shows hypokalemia (which can also precipitate arrhythmias),
the level of 3.8 is borderline but the ventricular ectopy is the immediate life-threatening
concern. The other options represent expected or acceptable physiological responses.
**Question 4**
During the insertion of a pulmonary artery catheter (Swan-Ganz), the nurse observes a
sudden change in the waveform to a tall, square-peaked pattern with a diastolic
pressure that equals the pulmonary artery diastolic pressure. The patient reports
sudden chest pain and coughs up bright red blood. What is the priority nursing action?
☐ A. Inflate the balloon port to 1.5 mL to occlude the pulmonary artery and obtain a
wedge pressure
☑ B. Deflate the balloon immediately, turn the patient onto the left side with
Trendelenburg position, and notify the physician
☐ C. Advance the catheter 2-3 cm further to float into the pulmonary capillary bed
☐ D. Obtain a stat arterial blood gas to assess for hypoxemia secondary to pulmonary
embolism
**Rationale:** The waveform described indicates pulmonary artery rupture or
perforation, a catastrophic complication of PA catheterization. The tall, square wave
suggests the catheter has advanced too far with the balloon inflated, or the tip has
perforated the vessel wall. Blood is entering the airway (hemoptysis). The immediate
action is to deflate the balloon to prevent further trauma, position the patient with the
bleeding lung dependent (left side down) to prevent aspiration into the unaffected lung,
and call for emergency surgical intervention. Options A and C would worsen the
perforation. Option D delays critical life-saving interventions.
, **Question 5**
A patient presents with hypertrophic cardiomyopathy (HCM) and is symptomatic with
dyspnea on exertion. Which nursing intervention is contraindicated for this specific
pathophysiology?
☐ A. Administration of beta-adrenergic blockers such as metoprolol
☑ B. Aggressive diuresis with intravenous furosemide to reduce preload
☐ C. Maintenance of adequate hydration to prevent vasodilation
☐ D. Avoidance of strenuous isometric exercise
**Rationale:** In hypertrophic cardiomyopathy, the primary issue is a hyperdynamic,
non-compliant left ventricle with outflow tract obstruction (LVOTO) exacerbated by
decreased ventricular volume. Aggressive diuresis (Option B) reduces preload, which
shrinks the ventricular chamber size and worsens the obstruction, potentially causing
syncope or sudden cardiac death. These patients are preload dependent. Beta-blockers
(Option A) are first-line therapy to reduce heart rate and contractility. Hydration (Option
C) and avoiding strenuous activity (Option D) are appropriate recommendations to
maintain adequate ventricular filling and prevent exacerbation of obstruction.
**Question 6**
A patient with end-stage heart failure is undergoing evaluation for ventricular assist
device (VAD) placement as destination therapy. Which patient statement indicates a
correct understanding of the implications of living with a VAD?
☐ A. "I will need to take warfarin for the first month, but then I can switch to aspirin
alone."
☑ B. "I must check my driveline exit site daily for signs of infection, as this is the most
common route for pathogens."
☐ C. "Once the device is implanted, I will no longer need to take any heart failure
medications."
Comprehensive Final Examination (Academic
Year 2024–2025)
SECTION I: ADVANCED CARDIOVASCULAR NURSING
**Question 1**
A 72-year-old male presents with crushing substernal chest pain radiating to the jaw,
diaphoresis, and nausea. Vital signs reveal a blood pressure of 82/54 mmHg, heart rate
of 110 bpm, and respiratory rate of 24. The 12-lead ECG shows ST-segment elevation
in leads V1-V4 with reciprocal ST depression in leads II, III, and aVF. Which
hemodynamic parameter best differentiates cardiogenic shock from a simple STEMI in
this patient?
☐ A. Systolic blood pressure below 90 mmHg lasting more than 30 minutes with
adequate fluid resuscitation
☑ B. Cardiac index less than 2.2 L/min/m² and pulmonary capillary wedge pressure
greater than 18 mmHg
☐ C. Systemic vascular resistance index below 1500 dynes/sec/cm⁻⁵/m² refractory to
vasopressor therapy
☐ D. Mixed venous oxygen saturation exceeding 75% despite supplemental oxygen
delivery
**Rationale:** Cardiogenic shock is defined by tissue hypoperfusion due to primary
cardiac pump failure. The hemodynamic criteria include a cardiac index (CI) < 2.2
L/min/m² (indicating inadequate perfusion) coupled with elevated pulmonary capillary
wedge pressure (PCWP > 18 mmHg), indicating left ventricular failure and fluid backup
into the pulmonary circulation. While hypotension (Option A) is present, it is not specific
to shock without the perfusion metrics. Option C describes a inappropriate vasodilation
seen in septic shock, not the vasoconstrictive state of cardiogenic shock. Option D
,indicates adequate tissue oxygen extraction, which is contrary to the pathophysiology of
shock where SvO2 is typically low.
**Question 2**
Following an anterior wall myocardial infarction, a patient develops acute mitral
regurgitation due to papillary muscle rupture. Which physical assessment finding would
the nurse anticipate during auscultation?
☐ A. A harsh, crescendo-decrescendo systolic murmur heard best at the right upper
sternal border radiating to the carotids
☑ B. A holosystolic blowing murmur at the apex radiating toward the left axilla
☐ C. A diastolic rumbling murmur with an opening snap heard at the fifth intercostal
space, mid-clavicular line
☐ D. A pericardial friction rub best heard with the patient leaning forward during end-
expiration
**Rationale:** Acute mitral regurgitation from papillary muscle dysfunction or rupture
post-MI produces a holosystolic (pansystolic) murmur best heard at the cardiac apex.
The regurgitant flow directs blood back into the left atrium during systole, creating the
blowing quality and radiation toward the axilla. Option A describes aortic stenosis.
Option C describes mitral stenosis. Option D indicates pericarditis, which may occur as
Dressler’s syndrome but is unrelated to valvular rupture.
**Question 3**
A patient with chronic heart failure is receiving an intravenous infusion of milrinone.
Which assessment finding requires immediate intervention by the registered nurse?
☐ A. Increase in cardiac output from 4 L/min to 6 L/min
☐ B. Potassium level decreasing from 4.2 mEq/L to 3.8 mEq/L
☑ C. Ventricular ectopy increasing to 12 premature ventricular contractions per minute
,☐ D. Mean arterial pressure decreasing from 78 mmHg to 72 mmHg
**Rationale:** Milrinone is a phosphodiesterase-3 inhibitor with both inotropic and
vasodilatory properties. It increases myocardial oxygen consumption and can
precipitate ventricular arrhythmias, including life-threatening ventricular tachycardia. An
increase in ventricular ectopy to trigeminy or higher frequency (Option C) necessitates
immediate assessment, possible discontinuation of the infusion, and notification of the
provider. While Option B shows hypokalemia (which can also precipitate arrhythmias),
the level of 3.8 is borderline but the ventricular ectopy is the immediate life-threatening
concern. The other options represent expected or acceptable physiological responses.
**Question 4**
During the insertion of a pulmonary artery catheter (Swan-Ganz), the nurse observes a
sudden change in the waveform to a tall, square-peaked pattern with a diastolic
pressure that equals the pulmonary artery diastolic pressure. The patient reports
sudden chest pain and coughs up bright red blood. What is the priority nursing action?
☐ A. Inflate the balloon port to 1.5 mL to occlude the pulmonary artery and obtain a
wedge pressure
☑ B. Deflate the balloon immediately, turn the patient onto the left side with
Trendelenburg position, and notify the physician
☐ C. Advance the catheter 2-3 cm further to float into the pulmonary capillary bed
☐ D. Obtain a stat arterial blood gas to assess for hypoxemia secondary to pulmonary
embolism
**Rationale:** The waveform described indicates pulmonary artery rupture or
perforation, a catastrophic complication of PA catheterization. The tall, square wave
suggests the catheter has advanced too far with the balloon inflated, or the tip has
perforated the vessel wall. Blood is entering the airway (hemoptysis). The immediate
action is to deflate the balloon to prevent further trauma, position the patient with the
bleeding lung dependent (left side down) to prevent aspiration into the unaffected lung,
and call for emergency surgical intervention. Options A and C would worsen the
perforation. Option D delays critical life-saving interventions.
, **Question 5**
A patient presents with hypertrophic cardiomyopathy (HCM) and is symptomatic with
dyspnea on exertion. Which nursing intervention is contraindicated for this specific
pathophysiology?
☐ A. Administration of beta-adrenergic blockers such as metoprolol
☑ B. Aggressive diuresis with intravenous furosemide to reduce preload
☐ C. Maintenance of adequate hydration to prevent vasodilation
☐ D. Avoidance of strenuous isometric exercise
**Rationale:** In hypertrophic cardiomyopathy, the primary issue is a hyperdynamic,
non-compliant left ventricle with outflow tract obstruction (LVOTO) exacerbated by
decreased ventricular volume. Aggressive diuresis (Option B) reduces preload, which
shrinks the ventricular chamber size and worsens the obstruction, potentially causing
syncope or sudden cardiac death. These patients are preload dependent. Beta-blockers
(Option A) are first-line therapy to reduce heart rate and contractility. Hydration (Option
C) and avoiding strenuous activity (Option D) are appropriate recommendations to
maintain adequate ventricular filling and prevent exacerbation of obstruction.
**Question 6**
A patient with end-stage heart failure is undergoing evaluation for ventricular assist
device (VAD) placement as destination therapy. Which patient statement indicates a
correct understanding of the implications of living with a VAD?
☐ A. "I will need to take warfarin for the first month, but then I can switch to aspirin
alone."
☑ B. "I must check my driveline exit site daily for signs of infection, as this is the most
common route for pathogens."
☐ C. "Once the device is implanted, I will no longer need to take any heart failure
medications."
