NUR 2502 / NUR2502: Multidimensional
Care III / MDC 3 Exam 2 Review (Latest
2025/ 2026) Rasmussen College
1. A patient with heart failure has a morning weight increase of 3
pounds since yesterday. Which action should the nurse take first?
A. Restrict fluids to 1000 mL/day
B. Administer a PRN dose of furosemide as ordered
C. Notify the healthcare provider
D. Increase the oxygen flow rate
Correct ,,,answer,,,,: B
Rationale: A weight gain of 2-3 pounds in 24 hours indicates fluid
retention. The priority is to administer a loop diuretic as ordered to
promote diuresis. The provider should be notified, but giving the
diuretic is an independent nursing action. Fluid restriction is not
immediate.
2. A patient with heart failure has crackles in all lung fields, an S3
gallop, and jugular venous distention. These findings indicate:
A. Right-sided heart failure only
B. Left-sided heart failure only
C. Biventricular failure
D. Pericarditis
Correct ,,,answer,,,,: C
Rationale: Crackles and S3 indicate left-sided failure (pulmonary
congestion). JVD indicates right-sided failure (systemic congestion).
Together they suggest biventricular failure.
,3. Which laboratory value is most important to monitor before
administering digoxin?
A. Serum potassium
B. Serum sodium
C. Blood urea nitrogen
D. Hemoglobin
Correct ,,,answer,,,,: A
Rationale: Hypokalemia increases the risk of digoxin toxicity, which
can cause life-threatening dysrhythmias. Serum potassium should
be within normal range before digoxin administration.
4. A patient with hypertension is started on hydrochlorothiazide.
The nurse should teach the patient to report which adverse effect?
A. Weight gain
B. Muscle weakness or cramps
C. Dry cough
D. Bradycardia
Correct ,,,answer,,,,: B
Rationale: Thiazide diuretics can cause hypokalemia, leading to
muscle weakness, cramps, and fatigue. Dry cough is associated with
ACE inhibitors. Bradycardia is not typical.
5. A patient with stable angina develops chest pain while ambulating
in the hallway. The nurse's priority action is:
A. Administer nitroglycerin sublingual
B. Have the patient sit down and rest
C. Obtain a 12-lead ECG
D. Notify the provider
Correct ,,,answer,,,,: B
Rationale: For stable angina, the first step is to stop activity and rest,
which decreases myocardial oxygen demand. If pain does not
subside, then nitroglycerin is given. The nurse should have the
patient sit down immediately.
,6. A patient is prescribed nitroglycerin transdermal patch. Which
instruction is correct?
A. Apply the patch to the same site daily
B. Remove the patch for 10-12 hours each day to prevent tolerance
C. The patch can be cut in half for a lower dose
D. Apply the patch only when chest pain occurs
Correct ,,,answer,,,,: B
Rationale: To prevent nitrate tolerance, the patch should be
removed for 10-12 hours daily (usually at night). Sites should be
rotated. Patches should not be cut.
7. A patient with atrial fibrillation has a heart rate of 150 bpm and is
hypotensive. The nurse should prepare for:
A. Synchronized cardioversion
B. Administration of IV diltiazem
C. Administration of oral metoprolol
D. Defibrillation
Correct ,,,answer,,,,: A
Rationale: Unstable atrial fibrillation with hypotension requires
immediate synchronized cardioversion. Chemical rate control would
be too slow. Defibrillation is for pulseless rhythms.
8. A patient with a new diagnosis of heart failure is prescribed
lisinopril. The nurse should monitor for which adverse effect,
especially after the first dose?
A. Hyperkalemia
B. First-dose hypotension
C. Dry cough
D. Angioedema
Correct ,,,answer,,,,: B
Rationale: ACE inhibitors can cause significant hypotension after the
first dose, especially in patients who are volume-depleted. The
nurse should monitor blood pressure closely.
, 9. A patient with a mechanical heart valve is taking warfarin. The
INR is 4.5. The patient has no signs of bleeding. The nurse should:
A. Administer vitamin K immediately
B. Hold the next dose of warfarin and notify the provider
C. Give an additional dose of warfarin
D. Administer protamine sulfate
Correct ,,,answer,,,,: B
Rationale: Therapeutic INR for mechanical valves is typically 2.5-3.5.
An INR of 4.5 is elevated. The nurse should hold the next dose and
notify the provider for further instruction. Vitamin K is given for
severe elevation with bleeding.
10. A patient with peripheral artery disease complains of leg pain
when walking that resolves with rest. This is called:
A. Rest pain
B. Intermittent claudication
C. Venous insufficiency
D. Neuropathic pain
Correct ,,,answer,,,,: B
Rationale: Intermittent claudication is muscle pain (cramping) in
the legs that occurs with exercise and is relieved by rest, caused by
inadequate blood flow due to PAD.
11. A patient with deep vein thrombosis is receiving a heparin
infusion. The aPTT is 110 seconds (normal 25-35). The nurse
should:
A. Continue the infusion at the same rate
B. Decrease the infusion rate per protocol
C. Stop the infusion and administer protamine
D. Notify the provider immediately
Correct ,,,answer,,,,: B
Rationale: The therapeutic aPTT range is typically 1.5-2.5 times
normal (approx. 60-80 seconds). 110 seconds is supratherapeutic.
Care III / MDC 3 Exam 2 Review (Latest
2025/ 2026) Rasmussen College
1. A patient with heart failure has a morning weight increase of 3
pounds since yesterday. Which action should the nurse take first?
A. Restrict fluids to 1000 mL/day
B. Administer a PRN dose of furosemide as ordered
C. Notify the healthcare provider
D. Increase the oxygen flow rate
Correct ,,,answer,,,,: B
Rationale: A weight gain of 2-3 pounds in 24 hours indicates fluid
retention. The priority is to administer a loop diuretic as ordered to
promote diuresis. The provider should be notified, but giving the
diuretic is an independent nursing action. Fluid restriction is not
immediate.
2. A patient with heart failure has crackles in all lung fields, an S3
gallop, and jugular venous distention. These findings indicate:
A. Right-sided heart failure only
B. Left-sided heart failure only
C. Biventricular failure
D. Pericarditis
Correct ,,,answer,,,,: C
Rationale: Crackles and S3 indicate left-sided failure (pulmonary
congestion). JVD indicates right-sided failure (systemic congestion).
Together they suggest biventricular failure.
,3. Which laboratory value is most important to monitor before
administering digoxin?
A. Serum potassium
B. Serum sodium
C. Blood urea nitrogen
D. Hemoglobin
Correct ,,,answer,,,,: A
Rationale: Hypokalemia increases the risk of digoxin toxicity, which
can cause life-threatening dysrhythmias. Serum potassium should
be within normal range before digoxin administration.
4. A patient with hypertension is started on hydrochlorothiazide.
The nurse should teach the patient to report which adverse effect?
A. Weight gain
B. Muscle weakness or cramps
C. Dry cough
D. Bradycardia
Correct ,,,answer,,,,: B
Rationale: Thiazide diuretics can cause hypokalemia, leading to
muscle weakness, cramps, and fatigue. Dry cough is associated with
ACE inhibitors. Bradycardia is not typical.
5. A patient with stable angina develops chest pain while ambulating
in the hallway. The nurse's priority action is:
A. Administer nitroglycerin sublingual
B. Have the patient sit down and rest
C. Obtain a 12-lead ECG
D. Notify the provider
Correct ,,,answer,,,,: B
Rationale: For stable angina, the first step is to stop activity and rest,
which decreases myocardial oxygen demand. If pain does not
subside, then nitroglycerin is given. The nurse should have the
patient sit down immediately.
,6. A patient is prescribed nitroglycerin transdermal patch. Which
instruction is correct?
A. Apply the patch to the same site daily
B. Remove the patch for 10-12 hours each day to prevent tolerance
C. The patch can be cut in half for a lower dose
D. Apply the patch only when chest pain occurs
Correct ,,,answer,,,,: B
Rationale: To prevent nitrate tolerance, the patch should be
removed for 10-12 hours daily (usually at night). Sites should be
rotated. Patches should not be cut.
7. A patient with atrial fibrillation has a heart rate of 150 bpm and is
hypotensive. The nurse should prepare for:
A. Synchronized cardioversion
B. Administration of IV diltiazem
C. Administration of oral metoprolol
D. Defibrillation
Correct ,,,answer,,,,: A
Rationale: Unstable atrial fibrillation with hypotension requires
immediate synchronized cardioversion. Chemical rate control would
be too slow. Defibrillation is for pulseless rhythms.
8. A patient with a new diagnosis of heart failure is prescribed
lisinopril. The nurse should monitor for which adverse effect,
especially after the first dose?
A. Hyperkalemia
B. First-dose hypotension
C. Dry cough
D. Angioedema
Correct ,,,answer,,,,: B
Rationale: ACE inhibitors can cause significant hypotension after the
first dose, especially in patients who are volume-depleted. The
nurse should monitor blood pressure closely.
, 9. A patient with a mechanical heart valve is taking warfarin. The
INR is 4.5. The patient has no signs of bleeding. The nurse should:
A. Administer vitamin K immediately
B. Hold the next dose of warfarin and notify the provider
C. Give an additional dose of warfarin
D. Administer protamine sulfate
Correct ,,,answer,,,,: B
Rationale: Therapeutic INR for mechanical valves is typically 2.5-3.5.
An INR of 4.5 is elevated. The nurse should hold the next dose and
notify the provider for further instruction. Vitamin K is given for
severe elevation with bleeding.
10. A patient with peripheral artery disease complains of leg pain
when walking that resolves with rest. This is called:
A. Rest pain
B. Intermittent claudication
C. Venous insufficiency
D. Neuropathic pain
Correct ,,,answer,,,,: B
Rationale: Intermittent claudication is muscle pain (cramping) in
the legs that occurs with exercise and is relieved by rest, caused by
inadequate blood flow due to PAD.
11. A patient with deep vein thrombosis is receiving a heparin
infusion. The aPTT is 110 seconds (normal 25-35). The nurse
should:
A. Continue the infusion at the same rate
B. Decrease the infusion rate per protocol
C. Stop the infusion and administer protamine
D. Notify the provider immediately
Correct ,,,answer,,,,: B
Rationale: The therapeutic aPTT range is typically 1.5-2.5 times
normal (approx. 60-80 seconds). 110 seconds is supratherapeutic.
