NSG 430 Exam 4 – GCU Adult Health Nursing II – (2026)
Actual Questions & Answers — 100 Questions
Section 1: Cardiovascular Disorders (Questions 1-10)
1 A patient with acute decompensated heart failure presents with pulmonary edema and a blood pressure of 90/60
mm Hg. Which of the following hemodynamic profiles is most consistent with this presentation, and what is the
priority intervention?
A) High cardiac output, low systemic vascular resistance; administer intravenous fluids
B) Low cardiac output, high systemic vascular resistance; initiate inotropic support with dobutamine
C) Low cardiac output, low systemic vascular resistance; administer vasopressin
D) High cardiac output, high systemic vascular resistance; start nitroprusside
Answer: B
Rationale: Acute decompensated heart failure with hypotension typically reflects low cardiac output and
compensatory high systemic vascular resistance (SVR). Inotropic support (e.g., dobutamine) improves contractility
and cardiac output. Fluids would worsen pulmonary edema; vasopressors may be considered but dobutamine is
first-line for low-output failure.
2 A patient in the cardiac intensive care unit has a pulmonary artery catheter in place. The pulmonary artery
occlusion pressure (PAOP) is 24 mm Hg, and the cardiac index is 1.8 L/min/m². Which of the following
conditions is most likely, and what intervention should be prioritized?
A) Cardiogenic shock; administer furosemide and consider intra-aortic balloon pump
B) Hypovolemic shock; administer a 500 mL bolus of normal saline
C) Distributive shock; start norepinephrine
D) Obstructive shock; prepare for pericardiocentesis
Answer: A
Rationale: Elevated PAOP (>18 mm Hg) with low cardiac index (<2.2 L/min/m²) indicates cardiogenic shock with
pulmonary congestion. Diuresis reduces preload, and an intra-aortic balloon pump augments coronary perfusion
and decreases afterload. Hypovolemic shock would show low PAOP; distributive shock low SVR; obstructive
shock would have equalization of diastolic pressures.
3 A patient with chronic heart failure and a left ventricular ejection fraction of 30% is being initiated on
guideline-directed medical therapy. Which of the following combinations of medications has been shown to
reduce mortality in clinical trials and is recommended as first-line?
A) Metoprolol tartrate, digoxin, and spironolactone
B) Carvedilol, lisinopril, and furosemide as needed
C) Sacubitril/valsartan, bisoprolol, and spironolactone
D) Amlodipine, losartan, and hydrochlorothiazide
Answer: C
Rationale: Sacubitril/valsartan (ARNI) has demonstrated superior mortality reduction compared to ACE inhibitors
in PARADIGM-HF. Beta-blockers (bisoprolol, carvedilol, metoprolol succinate) and mineralocorticoid receptor
antagonists (spironolactone) are also mortality-reducing. Option C combines these evidence-based agents. Digoxin
and furosemide are symptom-relieving but not mortality-reducing; amlodipine and HCTZ are not indicated.
,4 During a cardiac arrest due to ventricular fibrillation, a patient receives defibrillation and amiodarone. After
return of spontaneous circulation, the 12-lead ECG shows ST-segment elevation in leads V1-V4. What is the
most appropriate next step?
A) Administer thrombolytic therapy immediately
B) Proceed to emergent coronary angiography with percutaneous coronary intervention
C) Start therapeutic hypothermia and obtain a computed tomography scan of the head
D) Administer heparin and admit to the intensive care unit for medical management
Answer: B
Rationale: ST-segment elevation after cardiac arrest indicates acute myocardial infarction. Emergent coronary
angiography with PCI is the standard of care for STEMI, as it reduces mortality and improves outcomes.
Thrombolytics are an alternative if PCI is not available, but PCI is preferred. Therapeutic hypothermia is indicated
for comatose survivors but does not replace revascularization.
5 A patient with severe aortic stenosis is scheduled for transcatheter aortic valve replacement (TAVR). Which of
the following findings would be a contraindication to this procedure?
A) Bicuspid aortic valve morphology
B) Left ventricular ejection fraction of 35%
C) Porcelain aorta with extensive calcification
D) Severe mitral regurgitation
Answer: C
Rationale: Porcelain aorta (extensive calcification of the ascending aorta) is a relative contraindication to TAVR due
to increased risk of aortic rupture or embolization. Bicuspid aortic valve is not a contraindication but may require
careful sizing. Low LVEF and severe mitral regurgitation are not contraindications; TAVR may improve both.
6 A patient with atrial fibrillation is being anticoagulated with warfarin for stroke prevention. The international
normalized ratio (INR) is 4.8 and the patient has a small subdural hematoma identified on head CT. Which of
the following is the most appropriate management?
A) Hold warfarin, administer vitamin K 10 mg intravenously, and give four-factor prothrombin complex
concentrate (PCC)
B) Hold warfarin and administer fresh frozen plasma (FFP) 15 mL/kg
C) Hold warfarin, give vitamin K 1 mg orally, and repeat INR in 24 hours
D) Continue warfarin and start a heparin infusion for bridging
Answer: A
Rationale: Life-threatening bleeding (intracranial hemorrhage) with supratherapeutic INR requires rapid reversal.
Four-factor PCC provides immediate correction of coagulation factors, and vitamin K sustains reversal. FFP is less
effective and carries infection risk; low-dose oral vitamin K is too slow; continuing warfarin is dangerous.
7 A patient with hypertrophic cardiomyopathy (HCM) experiences syncope during exercise. Which of the
following pathophysiological mechanisms most likely contributes to this event, and what medication is
contraindicated?
A) Dynamic left ventricular outflow tract obstruction worsened by increased contractility; nitroglycerin is
contraindicated
B) Fixed coronary artery stenosis causing ischemia; beta-blockers are contraindicated
C) Ventricular arrhythmia due to myocardial fibrosis; amiodarone is contraindicated
D) Pulmonary hypertension leading to decreased preload; diuretics are contraindicated
Answer: A
, Rationale: In HCM, exercise increases contractility and heart rate, exacerbating LV outflow tract obstruction and
reducing cardiac output, causing syncope. Nitroglycerin reduces preload and afterload, worsening obstruction and
is contraindicated. Beta-blockers are first-line to reduce contractility and obstruction. Diuretics and vasodilators are
generally avoided.
8 A patient with an acute anterior ST-elevation myocardial infarction (STEMI) develops a new holosystolic
murmur at the apex radiating to the axilla. Which complication is most likely, and what is the priority
intervention?
A) Papillary muscle rupture causing acute mitral regurgitation; urgent surgical repair
B) Ventricular septal rupture causing left-to-right shunt; intra-aortic balloon pump and surgical closure
C) Free wall rupture causing cardiac tamponade; emergent pericardiocentesis
D) Ischemic mitral regurgitation due to left ventricular dilation; medical management with afterload reduction
Answer: A
Rationale: A new apical holosystolic murmur after anterior MI suggests papillary muscle rupture with acute mitral
regurgitation, which is a surgical emergency. Ventricular septal rupture produces a harsh holosystolic murmur at
the left lower sternal border; free wall rupture presents with electromechanical dissociation. Ischemic MR is usually
not acute or severe enough to cause a new murmur immediately.
9 A patient with a history of heart failure with reduced ejection fraction (HFrEF) is admitted with
decompensation. Laboratory results show serum sodium of 128 mEq/L, potassium 4.0 mEq/L, BUN 48 mg/dL,
creatinine 1.6 mg/dL. The patient is on lisinopril, metoprolol succinate, and furosemide. Which of the following
is the most appropriate adjustment to pharmacotherapy?
A) Discontinue lisinopril due to hyponatremia and worsening renal function
B) Increase furosemide dose to improve volume overload and correct hyponatremia
C) Continue all medications and add tolvaptan for hyponatremia
D) Hold metoprolol due to hypotension and bradycardia
Answer: C
Rationale: Hyponatremia in HFrEF often reflects dilution due to elevated ADH; tolvaptan, a vasopressin antagonist,
can correct sodium without worsening renal function. Discontinuing lisinopril would deprive the patient of
mortality benefit. Increasing furosemide may worsen hyponatremia by further activating the RAAS. Metoprolol
should be continued for mortality reduction unless symptomatic bradycardia/hypotension.
10 A patient with infective endocarditis involving the aortic valve develops sudden onset of severe dyspnea,
hypotension, and a new diastolic murmur. Which of the following is the most likely cause, and what is the
immediate management?
A) Aortic valve perforation causing acute aortic regurgitation; emergent valve replacement
B) Myocardial abscess causing heart block; temporary pacemaker placement
C) Septic embolization to coronary artery causing myocardial infarction; percutaneous coronary intervention
D) Rupture of sinus of Valsalva aneurysm causing aortocardiac shunt; surgical repair
Answer: A
Rationale: Acute aortic regurgitation from valve perforation in endocarditis presents with sudden pulmonary edema
and hypotension. Immediate valve replacement is life-saving. Heart block from abscess may occur but does not
cause sudden dyspnea and diastolic murmur. Septic coronary emboli are rare; sinus of Valsalva rupture is a
different entity.
Section 2: Respiratory Disorders (Questions 11-20)
Actual Questions & Answers — 100 Questions
Section 1: Cardiovascular Disorders (Questions 1-10)
1 A patient with acute decompensated heart failure presents with pulmonary edema and a blood pressure of 90/60
mm Hg. Which of the following hemodynamic profiles is most consistent with this presentation, and what is the
priority intervention?
A) High cardiac output, low systemic vascular resistance; administer intravenous fluids
B) Low cardiac output, high systemic vascular resistance; initiate inotropic support with dobutamine
C) Low cardiac output, low systemic vascular resistance; administer vasopressin
D) High cardiac output, high systemic vascular resistance; start nitroprusside
Answer: B
Rationale: Acute decompensated heart failure with hypotension typically reflects low cardiac output and
compensatory high systemic vascular resistance (SVR). Inotropic support (e.g., dobutamine) improves contractility
and cardiac output. Fluids would worsen pulmonary edema; vasopressors may be considered but dobutamine is
first-line for low-output failure.
2 A patient in the cardiac intensive care unit has a pulmonary artery catheter in place. The pulmonary artery
occlusion pressure (PAOP) is 24 mm Hg, and the cardiac index is 1.8 L/min/m². Which of the following
conditions is most likely, and what intervention should be prioritized?
A) Cardiogenic shock; administer furosemide and consider intra-aortic balloon pump
B) Hypovolemic shock; administer a 500 mL bolus of normal saline
C) Distributive shock; start norepinephrine
D) Obstructive shock; prepare for pericardiocentesis
Answer: A
Rationale: Elevated PAOP (>18 mm Hg) with low cardiac index (<2.2 L/min/m²) indicates cardiogenic shock with
pulmonary congestion. Diuresis reduces preload, and an intra-aortic balloon pump augments coronary perfusion
and decreases afterload. Hypovolemic shock would show low PAOP; distributive shock low SVR; obstructive
shock would have equalization of diastolic pressures.
3 A patient with chronic heart failure and a left ventricular ejection fraction of 30% is being initiated on
guideline-directed medical therapy. Which of the following combinations of medications has been shown to
reduce mortality in clinical trials and is recommended as first-line?
A) Metoprolol tartrate, digoxin, and spironolactone
B) Carvedilol, lisinopril, and furosemide as needed
C) Sacubitril/valsartan, bisoprolol, and spironolactone
D) Amlodipine, losartan, and hydrochlorothiazide
Answer: C
Rationale: Sacubitril/valsartan (ARNI) has demonstrated superior mortality reduction compared to ACE inhibitors
in PARADIGM-HF. Beta-blockers (bisoprolol, carvedilol, metoprolol succinate) and mineralocorticoid receptor
antagonists (spironolactone) are also mortality-reducing. Option C combines these evidence-based agents. Digoxin
and furosemide are symptom-relieving but not mortality-reducing; amlodipine and HCTZ are not indicated.
,4 During a cardiac arrest due to ventricular fibrillation, a patient receives defibrillation and amiodarone. After
return of spontaneous circulation, the 12-lead ECG shows ST-segment elevation in leads V1-V4. What is the
most appropriate next step?
A) Administer thrombolytic therapy immediately
B) Proceed to emergent coronary angiography with percutaneous coronary intervention
C) Start therapeutic hypothermia and obtain a computed tomography scan of the head
D) Administer heparin and admit to the intensive care unit for medical management
Answer: B
Rationale: ST-segment elevation after cardiac arrest indicates acute myocardial infarction. Emergent coronary
angiography with PCI is the standard of care for STEMI, as it reduces mortality and improves outcomes.
Thrombolytics are an alternative if PCI is not available, but PCI is preferred. Therapeutic hypothermia is indicated
for comatose survivors but does not replace revascularization.
5 A patient with severe aortic stenosis is scheduled for transcatheter aortic valve replacement (TAVR). Which of
the following findings would be a contraindication to this procedure?
A) Bicuspid aortic valve morphology
B) Left ventricular ejection fraction of 35%
C) Porcelain aorta with extensive calcification
D) Severe mitral regurgitation
Answer: C
Rationale: Porcelain aorta (extensive calcification of the ascending aorta) is a relative contraindication to TAVR due
to increased risk of aortic rupture or embolization. Bicuspid aortic valve is not a contraindication but may require
careful sizing. Low LVEF and severe mitral regurgitation are not contraindications; TAVR may improve both.
6 A patient with atrial fibrillation is being anticoagulated with warfarin for stroke prevention. The international
normalized ratio (INR) is 4.8 and the patient has a small subdural hematoma identified on head CT. Which of
the following is the most appropriate management?
A) Hold warfarin, administer vitamin K 10 mg intravenously, and give four-factor prothrombin complex
concentrate (PCC)
B) Hold warfarin and administer fresh frozen plasma (FFP) 15 mL/kg
C) Hold warfarin, give vitamin K 1 mg orally, and repeat INR in 24 hours
D) Continue warfarin and start a heparin infusion for bridging
Answer: A
Rationale: Life-threatening bleeding (intracranial hemorrhage) with supratherapeutic INR requires rapid reversal.
Four-factor PCC provides immediate correction of coagulation factors, and vitamin K sustains reversal. FFP is less
effective and carries infection risk; low-dose oral vitamin K is too slow; continuing warfarin is dangerous.
7 A patient with hypertrophic cardiomyopathy (HCM) experiences syncope during exercise. Which of the
following pathophysiological mechanisms most likely contributes to this event, and what medication is
contraindicated?
A) Dynamic left ventricular outflow tract obstruction worsened by increased contractility; nitroglycerin is
contraindicated
B) Fixed coronary artery stenosis causing ischemia; beta-blockers are contraindicated
C) Ventricular arrhythmia due to myocardial fibrosis; amiodarone is contraindicated
D) Pulmonary hypertension leading to decreased preload; diuretics are contraindicated
Answer: A
, Rationale: In HCM, exercise increases contractility and heart rate, exacerbating LV outflow tract obstruction and
reducing cardiac output, causing syncope. Nitroglycerin reduces preload and afterload, worsening obstruction and
is contraindicated. Beta-blockers are first-line to reduce contractility and obstruction. Diuretics and vasodilators are
generally avoided.
8 A patient with an acute anterior ST-elevation myocardial infarction (STEMI) develops a new holosystolic
murmur at the apex radiating to the axilla. Which complication is most likely, and what is the priority
intervention?
A) Papillary muscle rupture causing acute mitral regurgitation; urgent surgical repair
B) Ventricular septal rupture causing left-to-right shunt; intra-aortic balloon pump and surgical closure
C) Free wall rupture causing cardiac tamponade; emergent pericardiocentesis
D) Ischemic mitral regurgitation due to left ventricular dilation; medical management with afterload reduction
Answer: A
Rationale: A new apical holosystolic murmur after anterior MI suggests papillary muscle rupture with acute mitral
regurgitation, which is a surgical emergency. Ventricular septal rupture produces a harsh holosystolic murmur at
the left lower sternal border; free wall rupture presents with electromechanical dissociation. Ischemic MR is usually
not acute or severe enough to cause a new murmur immediately.
9 A patient with a history of heart failure with reduced ejection fraction (HFrEF) is admitted with
decompensation. Laboratory results show serum sodium of 128 mEq/L, potassium 4.0 mEq/L, BUN 48 mg/dL,
creatinine 1.6 mg/dL. The patient is on lisinopril, metoprolol succinate, and furosemide. Which of the following
is the most appropriate adjustment to pharmacotherapy?
A) Discontinue lisinopril due to hyponatremia and worsening renal function
B) Increase furosemide dose to improve volume overload and correct hyponatremia
C) Continue all medications and add tolvaptan for hyponatremia
D) Hold metoprolol due to hypotension and bradycardia
Answer: C
Rationale: Hyponatremia in HFrEF often reflects dilution due to elevated ADH; tolvaptan, a vasopressin antagonist,
can correct sodium without worsening renal function. Discontinuing lisinopril would deprive the patient of
mortality benefit. Increasing furosemide may worsen hyponatremia by further activating the RAAS. Metoprolol
should be continued for mortality reduction unless symptomatic bradycardia/hypotension.
10 A patient with infective endocarditis involving the aortic valve develops sudden onset of severe dyspnea,
hypotension, and a new diastolic murmur. Which of the following is the most likely cause, and what is the
immediate management?
A) Aortic valve perforation causing acute aortic regurgitation; emergent valve replacement
B) Myocardial abscess causing heart block; temporary pacemaker placement
C) Septic embolization to coronary artery causing myocardial infarction; percutaneous coronary intervention
D) Rupture of sinus of Valsalva aneurysm causing aortocardiac shunt; surgical repair
Answer: A
Rationale: Acute aortic regurgitation from valve perforation in endocarditis presents with sudden pulmonary edema
and hypotension. Immediate valve replacement is life-saving. Heart block from abscess may occur but does not
cause sudden dyspnea and diastolic murmur. Septic coronary emboli are rare; sinus of Valsalva rupture is a
different entity.
Section 2: Respiratory Disorders (Questions 11-20)
