NUR 2502 / NUR2502 Final Exam (Latest
): Multidimensional Care III /
MDC 3 - Rasmussen
Cardiovascular & Hematology Disorders (1-45)
1. A patient with a history of heart failure is admitted with acute
decompensated heart failure. The nurse assesses jugular venous
distention, 3+ pitting edema in the lower extremities, and crackles in the
lung bases. Which of the following is the priority nursing action?
A. Administer a loop diuretic as ordered.
B. Place the patient in a high-Fowler’s position.
C. Begin strict intake and output monitoring.
D. Weigh the patient to establish a baseline.
Correct ,,,answer,,,,: B
Rationale: The priority is to manage the patient's symptoms. Placing the
patient in a high-Fowler's position uses gravity to reduce preload and
improve lung expansion, which alleviates dyspnea and crackles. While
diuretics are the definitive treatment, positioning is an immediate,
independent nursing action to support ventilation.
2. A nurse is caring for a patient with mitral valve stenosis. On
auscultation, what is the classic heart sound the nurse expects to hear?
A. A high-pitched, blowing systolic murmur at the apex.
B. A low-pitched, rumbling diastolic murmur at the apex.
,C. A mid-systolic click followed by a late systolic murmur.
D. A harsh, crescendo-decrescendo murmur at the right sternal border.
Correct ,,,answer,,,,: B
Rationale: Mitral valve stenosis, a narrowing of the mitral valve orifice,
impedes blood flow from the left atrium to the left ventricle during
diastole, creating a low-pitched, rumbling diastolic murmur best heard at
the apex of the heart.
3. A patient is receiving a continuous heparin infusion for a deep vein
thrombosis. The nurse notes the patient has new-onset epistaxis and a
blood pressure of 100/60 mm Hg. Which of the following is the nurse’s
priority action?
A. Notify the healthcare provider immediately.
B. Stop the heparin infusion.
C. Apply direct pressure to the patient’s nares.
D. Decrease the heparin infusion rate by half.
Correct ,,,answer,,,,: A
Rationale: The patient is showing signs of bleeding (epistaxis,
hypotension) as a complication of heparin therapy. The nurse should
notify the provider immediately to get orders for an activated partial
thromboplastin time (aPTT) and potential reversal agents. Stopping the
infusion should be done per protocol or provider order, but notification is
the first step.
4. A client has received an overdose of warfarin. The healthcare provider
prescribes a stat dose of Vitamin K (phytonadione). Which outcome
indicates the medication was effective?
A. International Normalized Ratio (INR) begins to decrease.
B. Patient's platelet count returns to normal limits.
,C. The partial thromboplastin time (PTT) is prolonged.
D. Patient's bleeding time returns to normal range.
Correct ,,,answer,,,,: A
Rationale: Warfarin is a vitamin K antagonist that inhibits the synthesis of
clotting factors. The INR is the standardized measure used to monitor
warfarin's effect. Administering Vitamin K reverses this effect, leading to a
decrease in the INR.
5. A patient is 2 days post-major abdominal surgery and is receiving
enoxaparin 40mg subcutaneously once daily. The patient asks the nurse,
"Why am I getting a shot when I'm already on a blood thinner pill?" Which
response by the nurse is most accurate?
A. "The shot is to prevent blood clots; the pill is to treat them."
B. "The pill you are thinking of is likely aspirin, which is for pain, not clots."
C. "The enoxaparin is a precaution to prevent clots from forming while
your activity is limited."
D. "The injection is a stronger blood thinner to manage the inflammation
from surgery."
Correct ,,,answer,,,,: C
Rationale: Enoxaparin (Lovenox) is a low-molecular-weight heparin
(LMWH) often used for venous thromboembolism (VTE) prophylaxis in
hospitalized, post-surgical patients. Its purpose is to prevent the
formation of deep vein thrombosis (DVT) while the patient has decreased
mobility. Warfarin is typically used for long-term treatment or prophylaxis.
6. A nurse is assessing a patient with suspected infective endocarditis.
Which assessment finding is the most specific to this diagnosis?
A. Fever and chills.
B. New or changing heart murmur.
, C. Fatigue and night sweats.
D. Petechiae on the conjunctiva.
Correct ,,,answer,,,,: B
Rationale: A new or changing heart murmur is a hallmark sign of infective
endocarditis, caused by vegetations on the heart valves. Fever, malaise,
and petechiae are non-specific signs of infection, but a murmur points
directly to a valvular pathology.
7. A patient with chronic anemia is prescribed ferrous sulfate. To enhance
the absorption of this medication, the nurse should instruct the patient to
take it with which substance?
A. A glass of milk.
B. A cup of coffee.
C. A glass of orange juice.
D. An antacid tablet.
Correct ,,,answer,,,,: C
Rationale: Vitamin C (ascorbic acid) significantly enhances the absorption
of non-heme iron from the gastrointestinal tract. Taking ferrous sulfate
with a source of vitamin C, like orange juice, is a key patient teaching
point. Dairy, coffee, and antacids can decrease absorption.
8. A patient in the ICU has just been diagnosed with a hypertensive
emergency. The patient's blood pressure is 220/120 mm Hg. The
healthcare provider prescribes a sodium nitroprusside infusion. What is
the nurse's priority action?
A. Place the patient in Trendelenburg position to promote cerebral
perfusion.
B. Administer a 500 mL normal saline bolus to prevent hypotension.
C. Ensure the IV line and infusion pump are not connected to any other
drips.
): Multidimensional Care III /
MDC 3 - Rasmussen
Cardiovascular & Hematology Disorders (1-45)
1. A patient with a history of heart failure is admitted with acute
decompensated heart failure. The nurse assesses jugular venous
distention, 3+ pitting edema in the lower extremities, and crackles in the
lung bases. Which of the following is the priority nursing action?
A. Administer a loop diuretic as ordered.
B. Place the patient in a high-Fowler’s position.
C. Begin strict intake and output monitoring.
D. Weigh the patient to establish a baseline.
Correct ,,,answer,,,,: B
Rationale: The priority is to manage the patient's symptoms. Placing the
patient in a high-Fowler's position uses gravity to reduce preload and
improve lung expansion, which alleviates dyspnea and crackles. While
diuretics are the definitive treatment, positioning is an immediate,
independent nursing action to support ventilation.
2. A nurse is caring for a patient with mitral valve stenosis. On
auscultation, what is the classic heart sound the nurse expects to hear?
A. A high-pitched, blowing systolic murmur at the apex.
B. A low-pitched, rumbling diastolic murmur at the apex.
,C. A mid-systolic click followed by a late systolic murmur.
D. A harsh, crescendo-decrescendo murmur at the right sternal border.
Correct ,,,answer,,,,: B
Rationale: Mitral valve stenosis, a narrowing of the mitral valve orifice,
impedes blood flow from the left atrium to the left ventricle during
diastole, creating a low-pitched, rumbling diastolic murmur best heard at
the apex of the heart.
3. A patient is receiving a continuous heparin infusion for a deep vein
thrombosis. The nurse notes the patient has new-onset epistaxis and a
blood pressure of 100/60 mm Hg. Which of the following is the nurse’s
priority action?
A. Notify the healthcare provider immediately.
B. Stop the heparin infusion.
C. Apply direct pressure to the patient’s nares.
D. Decrease the heparin infusion rate by half.
Correct ,,,answer,,,,: A
Rationale: The patient is showing signs of bleeding (epistaxis,
hypotension) as a complication of heparin therapy. The nurse should
notify the provider immediately to get orders for an activated partial
thromboplastin time (aPTT) and potential reversal agents. Stopping the
infusion should be done per protocol or provider order, but notification is
the first step.
4. A client has received an overdose of warfarin. The healthcare provider
prescribes a stat dose of Vitamin K (phytonadione). Which outcome
indicates the medication was effective?
A. International Normalized Ratio (INR) begins to decrease.
B. Patient's platelet count returns to normal limits.
,C. The partial thromboplastin time (PTT) is prolonged.
D. Patient's bleeding time returns to normal range.
Correct ,,,answer,,,,: A
Rationale: Warfarin is a vitamin K antagonist that inhibits the synthesis of
clotting factors. The INR is the standardized measure used to monitor
warfarin's effect. Administering Vitamin K reverses this effect, leading to a
decrease in the INR.
5. A patient is 2 days post-major abdominal surgery and is receiving
enoxaparin 40mg subcutaneously once daily. The patient asks the nurse,
"Why am I getting a shot when I'm already on a blood thinner pill?" Which
response by the nurse is most accurate?
A. "The shot is to prevent blood clots; the pill is to treat them."
B. "The pill you are thinking of is likely aspirin, which is for pain, not clots."
C. "The enoxaparin is a precaution to prevent clots from forming while
your activity is limited."
D. "The injection is a stronger blood thinner to manage the inflammation
from surgery."
Correct ,,,answer,,,,: C
Rationale: Enoxaparin (Lovenox) is a low-molecular-weight heparin
(LMWH) often used for venous thromboembolism (VTE) prophylaxis in
hospitalized, post-surgical patients. Its purpose is to prevent the
formation of deep vein thrombosis (DVT) while the patient has decreased
mobility. Warfarin is typically used for long-term treatment or prophylaxis.
6. A nurse is assessing a patient with suspected infective endocarditis.
Which assessment finding is the most specific to this diagnosis?
A. Fever and chills.
B. New or changing heart murmur.
, C. Fatigue and night sweats.
D. Petechiae on the conjunctiva.
Correct ,,,answer,,,,: B
Rationale: A new or changing heart murmur is a hallmark sign of infective
endocarditis, caused by vegetations on the heart valves. Fever, malaise,
and petechiae are non-specific signs of infection, but a murmur points
directly to a valvular pathology.
7. A patient with chronic anemia is prescribed ferrous sulfate. To enhance
the absorption of this medication, the nurse should instruct the patient to
take it with which substance?
A. A glass of milk.
B. A cup of coffee.
C. A glass of orange juice.
D. An antacid tablet.
Correct ,,,answer,,,,: C
Rationale: Vitamin C (ascorbic acid) significantly enhances the absorption
of non-heme iron from the gastrointestinal tract. Taking ferrous sulfate
with a source of vitamin C, like orange juice, is a key patient teaching
point. Dairy, coffee, and antacids can decrease absorption.
8. A patient in the ICU has just been diagnosed with a hypertensive
emergency. The patient's blood pressure is 220/120 mm Hg. The
healthcare provider prescribes a sodium nitroprusside infusion. What is
the nurse's priority action?
A. Place the patient in Trendelenburg position to promote cerebral
perfusion.
B. Administer a 500 mL normal saline bolus to prevent hypotension.
C. Ensure the IV line and infusion pump are not connected to any other
drips.
