Adult Medical Surgical Nursing Exam: 200 NCLEX
Questions with Correct Detailed Answers &
Detailed Rationales Latest update
Introduction
Welcome to the Adult Medical Surgical Nursing Exam: a comprehensive, high-yield
question bank containing 200 practice questions covering cardiovascular,
respiratory, gastrointestinal, renal, endocrine, neurologic, musculoskeletal,
hematologic, immunologic, and perioperative nursing. Unlike standard study
guides, every correct answer is presented in bold for immediate visual recognition,
and every rationale is written in italics to differentiate the explanation from the
question stem.
PART 1 (Questions 1–50)
Question 1
A nurse is assessing a client with heart failure who reports shortness of breath and
crackles in both lung bases. Which finding would the nurse expect?
A. Increased jugular venous pressure
B. Decreased oxygen saturation
C. Bounding peripheral pulses
D. Increased urinary output
Rationale: Decreased oxygen saturation (hypoxemia) is common in heart failure
due to pulmonary congestion and impaired gas exchange. JVP may be elevated,
but the most immediate finding with crackles and dyspnea is low SpO2.
,Question 2
A post-operative client develops sudden chest pain, dyspnea, and tachycardia. The nurse
suspects pulmonary embolism. Which diagnostic test is most definitive?
A. D-dimer
B. Chest x-ray
C. CT pulmonary angiography
D. Ventilation-perfusion (V/Q) scan
Rationale: CT pulmonary angiography is the gold standard for detecting
pulmonary emboli. D-dimer is sensitive but not specific; V/Q scan is used if CT
contraindicated.
Question 3
A client with cirrhosis has asterixis. What dietary modification should the nurse
anticipate?
A. High sodium intake
B. Low potassium intake
C. Low protein intake
D. High fluid intake
Rationale: Asterixis (liver flap) indicates hepatic encephalopathy from ammonia
accumulation. Low protein intake reduces ammonia production.
Question 4
A diabetic client has a blood glucose of 48 mg/dL and is conscious. What should the
nurse administer first?
A. Glucagon IM
B. 15 grams of oral fast-acting carbohydrate
C. IV dextrose 50%
D. Regular insulin
Rationale: For conscious hypoglycemia, 15g oral carbohydrate (e.g., glucose
tablets, juice) is safe and rapid. IV dextrose is for unconscious patients; glucagon is
for severe cases without IV access.
Question 5
A client with chronic kidney disease (CKD) has a potassium level of 6.8 mEq/L. What
cardiac change would the nurse monitor?
A. Peaked T waves
B. Widened QRS
C. Prolonged PR interval
D. U waves
*Rationale: Hyperkalemia (K+ >6.0) causes tall, peaked T waves. Widened QRS and
prolonged PR occur at higher levels; U waves are seen in hypokalemia.*
,Question 6
A client on a ventilator has a sudden drop in oxygen saturation and absent breath
sounds on the right. What should the nurse suspect?
A. Tension pneumothorax
B. Mucus plug
C. Pulmonary edema
D. Atelectasis
Rationale: Absent breath sounds unilaterally with sudden desaturation in a
ventilated patient suggests tension pneumothorax (often from barotrauma).
Immediate needle decompression is needed.
Question 7
A client with acute pancreatitis reports severe abdominal pain that radiates to the back.
Which laboratory finding is most specific?
A. Elevated ALT
B. Elevated total bilirubin
C. Elevated serum lipase
D. Leukocytosis
Rationale: Lipase is the most specific pancreatic enzyme (remains elevated longer
than amylase). ALT/bilirubin suggest biliary causes but not pancreatitis
specifically.
Question 8
A client with a new colostomy reports a dark red stoma. The nurse’s priority action is to:
A. Document the finding
B. Notify the surgeon immediately
C. Apply a stoma adhesive
D. Irrigate the colostomy
Rationale: A dark red or purplish stoma indicates ischemia or necrosis, a surgical
emergency. A healthy stoma should be pink/red and moist.
Question 9
Which symptom differentiates an ischemic stroke from a hemorrhagic stroke?
A. Hemiparesis
B. Sudden severe headache (“thunderclap”)
C. Aphasia
D. Facial droop
Rationale: Hemorrhagic stroke often presents with a sudden, severe “thunderclap”
headache due to bleeding and increased ICP. Ischemic stroke pain is less common.
, Question 10
A client with asthma has a peak expiratory flow (PEF) of 45% of personal best. The nurse
expects:
A. Short-acting beta agonist (SABA) and oral corticosteroids
B. No change in medication
C. Long-acting beta agonist only
D. Intubation immediately
*Rationale: PEF 40-50% indicates a severe exacerbation, requiring SABA
(nebulized) plus systemic steroids. Intubation is for PEF <25% or altered mental
status.*
Question 11
A client on warfarin has an INR of 4.5 with no bleeding. The nurse should:
A. Hold warfarin and administer vitamin K
B. Give fresh frozen plasma
C. Continue warfarin as ordered
D. Increase the warfarin dose
Rationale: For INR >4.5 without bleeding, warfarin is held and oral vitamin K
given per protocol. FFP is for active bleeding or very high INR (>10).
Question 12
A client with thyroid storm has a temperature of 104°F. Which intervention is a priority?
A. Administer levothyroxine
B. Cooling blankets and acetaminophen
C. Place on a warming mattress
D. Restrict all fluids
*Rationale: Hyperpyrexia in thyroid storm must be managed aggressively to
prevent CNS damage. Cooling blankets + acetaminophen (avoid aspirin – may
increase T4).*
Question 13
A nurse is caring for a client with a chest tube after lobectomy. What finding should be
reported immediately?
A. Continuous bubbling in the water seal chamber
B. Gentle tidaling with respirations
C. 100 mL of drainage in first hour
D. Serosanguineous drainage
*Rationale: Continuous bubbling in the water seal chamber indicates an air leak
(likely from lung or pleural space). Tidaling is normal; drainage up to 100 mL/hr is
expected post-op.*
Questions with Correct Detailed Answers &
Detailed Rationales Latest update
Introduction
Welcome to the Adult Medical Surgical Nursing Exam: a comprehensive, high-yield
question bank containing 200 practice questions covering cardiovascular,
respiratory, gastrointestinal, renal, endocrine, neurologic, musculoskeletal,
hematologic, immunologic, and perioperative nursing. Unlike standard study
guides, every correct answer is presented in bold for immediate visual recognition,
and every rationale is written in italics to differentiate the explanation from the
question stem.
PART 1 (Questions 1–50)
Question 1
A nurse is assessing a client with heart failure who reports shortness of breath and
crackles in both lung bases. Which finding would the nurse expect?
A. Increased jugular venous pressure
B. Decreased oxygen saturation
C. Bounding peripheral pulses
D. Increased urinary output
Rationale: Decreased oxygen saturation (hypoxemia) is common in heart failure
due to pulmonary congestion and impaired gas exchange. JVP may be elevated,
but the most immediate finding with crackles and dyspnea is low SpO2.
,Question 2
A post-operative client develops sudden chest pain, dyspnea, and tachycardia. The nurse
suspects pulmonary embolism. Which diagnostic test is most definitive?
A. D-dimer
B. Chest x-ray
C. CT pulmonary angiography
D. Ventilation-perfusion (V/Q) scan
Rationale: CT pulmonary angiography is the gold standard for detecting
pulmonary emboli. D-dimer is sensitive but not specific; V/Q scan is used if CT
contraindicated.
Question 3
A client with cirrhosis has asterixis. What dietary modification should the nurse
anticipate?
A. High sodium intake
B. Low potassium intake
C. Low protein intake
D. High fluid intake
Rationale: Asterixis (liver flap) indicates hepatic encephalopathy from ammonia
accumulation. Low protein intake reduces ammonia production.
Question 4
A diabetic client has a blood glucose of 48 mg/dL and is conscious. What should the
nurse administer first?
A. Glucagon IM
B. 15 grams of oral fast-acting carbohydrate
C. IV dextrose 50%
D. Regular insulin
Rationale: For conscious hypoglycemia, 15g oral carbohydrate (e.g., glucose
tablets, juice) is safe and rapid. IV dextrose is for unconscious patients; glucagon is
for severe cases without IV access.
Question 5
A client with chronic kidney disease (CKD) has a potassium level of 6.8 mEq/L. What
cardiac change would the nurse monitor?
A. Peaked T waves
B. Widened QRS
C. Prolonged PR interval
D. U waves
*Rationale: Hyperkalemia (K+ >6.0) causes tall, peaked T waves. Widened QRS and
prolonged PR occur at higher levels; U waves are seen in hypokalemia.*
,Question 6
A client on a ventilator has a sudden drop in oxygen saturation and absent breath
sounds on the right. What should the nurse suspect?
A. Tension pneumothorax
B. Mucus plug
C. Pulmonary edema
D. Atelectasis
Rationale: Absent breath sounds unilaterally with sudden desaturation in a
ventilated patient suggests tension pneumothorax (often from barotrauma).
Immediate needle decompression is needed.
Question 7
A client with acute pancreatitis reports severe abdominal pain that radiates to the back.
Which laboratory finding is most specific?
A. Elevated ALT
B. Elevated total bilirubin
C. Elevated serum lipase
D. Leukocytosis
Rationale: Lipase is the most specific pancreatic enzyme (remains elevated longer
than amylase). ALT/bilirubin suggest biliary causes but not pancreatitis
specifically.
Question 8
A client with a new colostomy reports a dark red stoma. The nurse’s priority action is to:
A. Document the finding
B. Notify the surgeon immediately
C. Apply a stoma adhesive
D. Irrigate the colostomy
Rationale: A dark red or purplish stoma indicates ischemia or necrosis, a surgical
emergency. A healthy stoma should be pink/red and moist.
Question 9
Which symptom differentiates an ischemic stroke from a hemorrhagic stroke?
A. Hemiparesis
B. Sudden severe headache (“thunderclap”)
C. Aphasia
D. Facial droop
Rationale: Hemorrhagic stroke often presents with a sudden, severe “thunderclap”
headache due to bleeding and increased ICP. Ischemic stroke pain is less common.
, Question 10
A client with asthma has a peak expiratory flow (PEF) of 45% of personal best. The nurse
expects:
A. Short-acting beta agonist (SABA) and oral corticosteroids
B. No change in medication
C. Long-acting beta agonist only
D. Intubation immediately
*Rationale: PEF 40-50% indicates a severe exacerbation, requiring SABA
(nebulized) plus systemic steroids. Intubation is for PEF <25% or altered mental
status.*
Question 11
A client on warfarin has an INR of 4.5 with no bleeding. The nurse should:
A. Hold warfarin and administer vitamin K
B. Give fresh frozen plasma
C. Continue warfarin as ordered
D. Increase the warfarin dose
Rationale: For INR >4.5 without bleeding, warfarin is held and oral vitamin K
given per protocol. FFP is for active bleeding or very high INR (>10).
Question 12
A client with thyroid storm has a temperature of 104°F. Which intervention is a priority?
A. Administer levothyroxine
B. Cooling blankets and acetaminophen
C. Place on a warming mattress
D. Restrict all fluids
*Rationale: Hyperpyrexia in thyroid storm must be managed aggressively to
prevent CNS damage. Cooling blankets + acetaminophen (avoid aspirin – may
increase T4).*
Question 13
A nurse is caring for a client with a chest tube after lobectomy. What finding should be
reported immediately?
A. Continuous bubbling in the water seal chamber
B. Gentle tidaling with respirations
C. 100 mL of drainage in first hour
D. Serosanguineous drainage
*Rationale: Continuous bubbling in the water seal chamber indicates an air leak
(likely from lung or pleural space). Tidaling is normal; drainage up to 100 mL/hr is
expected post-op.*
