High Acuity Cardiac
A nurse is caring for a patient who just underwent a trans-aortic valve replacement (TAVR). Which nursing action has the highest priority during the first few hours post-procedure?
A. Encourage ambulation to prevent DVTs
B. Elevate the head of the bed to 45° to improve breathing
C. Monitor femoral access site for bleeding or hematoma formation
D. Administer a high-protein diet to promote wound healing
Correct Answer: C
Rationale: Early post-procedure care focuses on preventing vascular complications. Keeping the patient flat and monitoring the femoral site for bleeding are key priorities after catheter-based cardiac procedures.
The nurse notes that a patient under sedation responds only to painful stimuli and requires jaw support to maintain airway patency. How should this level of sedation be classified?
A. Minimal sedation
B. Moderate sedation
C. Deep sedation
D. General anesthesia
Correct Answer: C
Rationale: Deep sedation is characterized by purposeful response only to painful stimuli and potential need for airway assistance. This finding requires close monitoring and readiness for rescue interventions.
A patient with sepsis develops increasing dyspnea and tachypnea 48 hours after admission. ABG results show pH 7.48, PaCO₂ 30 mm Hg, and PaO₂ 65 mm Hg on 50% FiO₂. Which finding should the nurse interpret as an early indicator of ARDS?
A. Respiratory acidosis and hypercapnia
B. Hypoxemia unresponsive to oxygen therapy
C. Decreased respiratory rate and lethargy
D. Wheezing with productive cough
Correct Answer: B
Rationale: Early ARDS is marked by refractory hypoxemia—oxygenation fails to improve even with supplemental O₂. The alkalosis and low CO₂ reflect early hyperventilation before fatigue sets in.
A nurse wants to reduce health disparities on their behavioral health unit. Which nursing action most directly supports health equity?
A. Treating all patients the same regardless of background
B. Assessing for social determinants such as housing and access to care
C. Avoiding discussions about race, culture, or religion
D. Asking patients to adapt to hospital routines to maintain consistency
Correct Answer: B
Rationale: Identifying social determinants of health (SDOH)—like housing, transportation, or language barriers—helps the nurse address systemic inequities and tailor interventions for equitable care
A patient who recently lost their job says, “I’ve tried everything to find work, but nothing helps. I can’t sleep or think straight.” According to Caplan’s four phases of crisis development, which phase is this patient likely experiencing?
A. Phase 1: Trigger exposure
B. Phase 2: Failed problem-solving
C. Phase 3: Search for new solutions
D. Phase 4: Severe anxiety and disorganization
Correct Answer: B
Rationale: When usual problem-solving strategies fail and anxiety escalates, the patient enters Phase 2, increasing the risk of maladaptive responses or progressing into later crisis stages.
A patient with cardiogenic shock is supported by an IABP. The nurse recognizes effective balloon function when which occurs?
A. The balloon inflates during systole and deflates during diastole
B. The balloon inflates during diastole and deflates just before systole
C. The balloon inflates continuously to maintain preload
D. The balloon deflates during diastole to improve filling pressures
Correct Answer: B
Rationale: Inflation during diastole increases coronary perfusion; deflation before systole decreases afterload, enhancing cardiac output and oxygen delivery.
A nurse is monitoring a patient receiving moderate sedation for a colonoscopy. The provider asks the nurse to briefly assist with documentation while monitoring. What is the appropriate nursing response?
A. “I can assist as long as I keep an eye on the cardiac monitor.”
B. “I need to remain focused solely on monitoring the patient’s sedation status.”
C. “Let’s pause the procedure until I finish charting.”
D. “I can do both if I have the pulse oximeter on.”
Correct Answer: B
Rationale: During moderate sedation, the nurse’s only responsibility is continuous monitoring of the patient’s airway, breathing, circulation, and level of consciousness—no other duties should be performed.
A patient with COPD shows PaO₂ 58 mm Hg and PaCO₂ 60 mm Hg. The nurse identifies this as which type of respiratory failure?
A. Oxygenation failure
B. Ventilatory failure
C. Combined ventilatory and oxygenation failure
D. Acute lung injury
Correct Answer: C
Rationale: Elevated CO₂ indicates ventilatory failure, while low O₂ indicates oxygenation failure. The combination is typical in advanced COPD or ARDS.
A nurse caring for a patient from a different cultural background notices personal assumptions about the patient’s adherence to care. What is the first step the nurse should take?
A. Ignore the thought and continue with the care plan
B. Discuss these assumptions openly with the patient
C. Reflect on personal unconscious bias before interacting further
D. Document the bias in the patient’s chart
Correct Answer: C
Rationale: Self-awareness and reflection are the first steps in managing bias. Recognizing how unconscious perceptions may influence care promotes cultural humility and reduces health disparities
A 29-year-old woman presents to the emergency department after being assaulted by her partner. She states, “I have nowhere to go, and I don’t know what to do.” Which type of crisis does this represent?
A. Maturational/developmental crisis
B. Crisis reflecting psychopathology
C. Dispositional crisis
D. Anticipated life transition crisis
Correct Answer: C
Rationale: A dispositional crisis arises from an external stressor, such as domestic violence or abuse, requiring immediate safety planning and emotional support.
The nurse is assessing a patient on an Impella device for cardiogenic shock. Which finding requires immediate intervention?
A. Mean arterial pressure (MAP) of 70 mmHg
B. Absence of distal pulses in the affected limb
C. Urine output of 45 mL/hr
D. Heart rate of 95 bpm
Correct Answer: B
Rationale: Loss of distal pulses indicates possible limb ischemia due to catheter obstruction or dislodgement. This is an emergency and requires prompt provider notification.
A patient receiving moderate sedation with midazolam and fentanyl becomes difficult to arouse with shallow respirations and SpO₂ of 84%. Which medication should the nurse prepare to administer first?
A. Naloxone (Narcan)
B. Flumazenil (Romazicon)
C. Atropine
D. Epinephrine
Correct Answer: A
Rationale: Midazolam and fentanyl are commonly used together; however, respiratory depression is most often due to the opioid component. Naloxone reverses opioid-induced respiratory depression. If unresponsive, Flumazenil may follow.
A mechanically ventilated patient with ARDS has a PaO₂ of 50 mm Hg despite 100% FiO₂. Which nursing intervention should the nurse anticipate next?
A. Increase ventilator rate
B. Prepare for prone positioning
C. Suction the endotracheal tube
D. Decrease tidal volume
Correct Answer: B
Rationale: Prone positioning improves alveolar recruitment and oxygenation by redistributing perfusion. It’s a key collaborative intervention when hypoxemia persists despite maximal oxygen delivery.
When conducting a spiritual assessment using the FICA tool, the nurse asks, “What gives your life meaning?” This question corresponds to which part of the acronym?
A. Faith/Belief
B. Importance/Influence
C. Community
D. Address in Care
Correct Answer: A
Rationale: The “F” in FICA (Faith, Belief, Meaning) focuses on understanding the patient’s spiritual beliefs or sources of meaning, which may influence coping and decision-making
During the assessment phase of crisis intervention, which question best helps the nurse identify the patient’s coping capacity?
A. “What triggered this event for you?”
B. “Who do you usually turn to for support when you feel overwhelmed?”
C. “What are your goals for the next few weeks?”
D. “What resources are available in your community?”
Correct Answer: B
Rationale: Assessment includes identifying coping skills and support systems. Understanding who the patient relies on helps the nurse determine resilience and resources available to aid recovery.
A patient receiving veno-arterial ECMO for cardiogenic shock suddenly develops increased bleeding from cannula sites. Which nursing action is most appropriate?
A. Increase the ECMO flow rate to maintain perfusion
B. Notify the provider and prepare to obtain coagulation studies
C. Apply direct pressure and continue to monitor
D. Administer the scheduled dose of heparin
Correct Answer: B
Rationale: Bleeding may indicate anticoagulation imbalance. The nurse must stop heparin administration and assess coagulation parameters immediately per protocol.
The nurse is using the Aldrete Recovery Scale to assess readiness for discharge after procedural sedation. Which finding indicates the patient is not yet ready for discharge?
A. Oriented ×3 and follows commands
B. Oxygen saturation 95% on room air
C. BP 85/50 mmHg (baseline 120/80)
D. Able to move all extremities voluntarily
Correct Answer: C
Rationale: A blood pressure that remains >20% below baseline indicates incomplete hemodynamic recovery. The patient must achieve baseline stability before discharge.
A postoperative patient suddenly becomes anxious, tachypneic, and complains of chest pain and dyspnea. Which action should the nurse take first?
A. Call the rapid response team
B. Administer oxygen via non-rebreather mask
C. Prepare to draw a D-dimer level
D. Start an IV infusion of heparin
Correct Answer: B
Rationale: Immediate oxygen administration is the priority to reduce hypoxemia. After stabilizing breathing, the nurse activates emergency response and anticipates diagnostic and anticoagulation orders.
Which action best demonstrates culturally competent nursing care?
A. Asking all patients about their religion during intake
B. Providing the same discharge instructions to all patients for fairness
C. Using the CULTURE mnemonic to guide individualized assessments
D. Assuming family members will explain care instructions in their native language
Correct Answer: C
Rationale: The CULTURE mnemonic helps nurses provide patient-centered care by promoting awareness of one’s own biases, respect for diversity, and sensitivity to cultural differences
A patient on the behavioral health unit is pacing, clenching their fists, and shouting that staff “aren’t listening.” What is the nurse’s best initial action?
A. Call security and prepare for restraints
B. Confront the patient about inappropriate behavior
C. Maintain a safe distance and set verbal limits calmly
D. Leave the room and observe from the doorway
Correct Answer: C
Rationale: Early recognition of escalation and use of de-escalation techniques—such as maintaining distance, calm tone, and verbal limit setting—can prevent aggression and ensure safety.
During morning assessment, the nurse notes that the patient with a left ventricular assist device (LVAD) has no palpable pulse and the monitor shows a flat arterial line waveform. What is the best nursing action?
A. Begin CPR immediately
B. Check VAD power connections and battery function
C. Notify the provider of suspected cardiac arrest
D. Apply defibrillation pads and deliver a shock
Correct Answer: B
Rationale: Patients with continuous-flow VADs often lack a palpable pulse. First ensure that the device is functioning properly before initiating emergency interventions.
Before a procedure requiring moderate sedation, the nurse notices that the consent form is unsigned. The patient says, “Oh, the doctor just told me to sign it later.” What is the nurse’s best action?
A. Proceed with the procedure and have the provider obtain consent afterward
B. Obtain the patient’s signature as a witness
C. Hold the procedure and notify the provider immediately
D. Document “consent pending” and continue monitoring
Correct Answer: C
Rationale: Informed consent must be obtained by the provider before sedation begins. The nurse’s role is to verify completion and witness the signature—proceeding without consent is a legal violation.
Which patient is most at risk for developing ARDS?
A. 30-year-old with a closed femur fracture after skiing accident
B. 54-year-old with pancreatitis and severe hypotension
C. 42-year-old with asthma using inhaled corticosteroids
D. 65-year-old post-CABG with stable vitals
Correct Answer: B
Rationale: Severe pancreatitis and shock cause massive inflammatory mediator release, leading to increased capillary permeability and diffuse alveolar damage—hallmarks of ARDS.
During a psychiatric admission, a patient from a marginalized community expresses distrust of healthcare providers. What is the most therapeutic nursing response?
A. “You don’t need to worry—our hospital treats everyone the same.”
B. “Tell me more about your past experiences with healthcare.”
C. “I’ll have another nurse work with you if you prefer.”
D. “Trust takes time; let’s focus on your medication first.”
Correct Answer: B
Rationale: Trust-building begins with active listening and validation. Inviting patients to share experiences helps establish rapport and fosters an inclusive, trauma-informed relationship
Following a community disaster, a patient exhibits insomnia, irritability, and emotional numbness. Which nursing intervention demonstrates trauma-informed care?
A. Encourage the patient to describe every detail of the event
B. Reassure the patient that their reactions are normal and focus on safety and coping
C. Emphasize that the event is over and should be put behind them
D. Provide sedative medication immediately to reduce anxiety
Correct Answer: B
Rationale: Trauma-informed care prioritizes safety, empowerment, and normalization of stress reactions. The nurse supports adaptive coping without forcing discussion of traumatic details.