**The Med-Surg Mastery: Advanced Medical-
Surgical Nursing Certification**
1. A patient with chronic heart failure has a weight gain of 5 pounds in 3 days, crackles in the lung bases,
and 2+ pitting edema. Which intervention should the nurse implement first?
A) Restrict oral fluids to 1,000 mL/day
B) Administer furosemide 40 mg IV
C) Elevate the patient's legs above heart level
D) Insert an indwelling urinary catheter
💫RATIONALE✔️✔️: The patient is in acute decompensated heart failure with fluid overload. IV
furosemide rapidly reduces preload and relieves pulmonary congestion. Fluid restriction is important
but not first.
💫ANSWER✔️✔️: B) Administer furosemide 40 mg IV
---
2. A patient with cirrhosis has an ammonia level of 120 mcg/dL and is becoming increasingly confused.
Which medication order should the nurse question?
A) Lactulose 30 mL PO every 6 hours
B) Rifaximin 550 mg PO BID
C) Lorazepam 1 mg IV for agitation
D) Normal saline at 100 mL/hr
💫RATIONALE✔️✔️: Benzodiazepines (lorazepam) are metabolized by the liver and can precipitate or
worsen hepatic encephalopathy. Avoid sedatives in acute liver failure. Lactulose and rifaximin are
standard.
💫ANSWER✔️✔️: C) Lorazepam 1 mg IV for agitation
---
,3. A patient with a new diagnosis of type 1 diabetes is learning to self-administer insulin. The patient
draws up 20 units of NPH insulin, then 10 units of regular insulin in the same syringe. Which action is
incorrect?
A) Injecting air into the NPH vial first
B) Injecting air into the regular vial second
C) Drawing up the regular insulin first
D) Drawing up the NPH insulin first
💫RATIONALE✔️✔️: When mixing insulins, draw up the clear (regular) first, then the cloudy (NPH).
Drawing up NPH first contaminates the regular vial. The air injection order is into NPH first, then regular.
💫ANSWER✔️✔️: D) Drawing up the NPH insulin first
---
4. A patient with a deep vein thrombosis (DVT) is on a heparin drip. The aPTT is 45 seconds (goal 60-80).
What is the priority action?
A) Increase the heparin drip rate per protocol
B) Administer a heparin bolus of 80 units/kg
C) Draw aPTT in 6 hours
D) Notify the provider of subtherapeutic level
💫RATIONALE✔️✔️: Subtherapeutic aPTT requires an increase in infusion rate per nomogram. Many
nomograms also include a bolus if aPTT is significantly low. Increase rate and consider bolus.
💫ANSWER✔️✔️: A) Increase the heparin drip rate per protocol
---
5. A patient with chronic kidney disease (CKD) has a potassium level of 6.2 mEq/L. The ECG shows
peaked T waves. What is the priority action?
A) Administer sodium polystyrene sulfonate (Kayexalate)
B) Administer calcium gluconate 1 g IV
C) Administer insulin 10 units IV with dextrose 25 g IV
D) Prepare for hemodialysis
,💫RATIONALE✔️✔️: Hyperkalemia with ECG changes requires immediate cardiac membrane stabilization
with IV calcium gluconate. Then shift potassium with insulin/dextrose. Kayexalate and dialysis remove
potassium but are not first for emergency stabilization.
💫ANSWER✔️✔️: B) Administer calcium gluconate 1 g IV
---
6. A patient with pancreatitis has a calcium level of 6.8 mg/dL. Which finding is most likely the cause?
A) Hypoalbuminemia
B) Saponification of calcium in the abdomen
C) Malabsorption of vitamin D
D) Hyperparathyroidism
💫RATIONALE✔️✔️: In acute pancreatitis, free fatty acids bind to calcium, forming calcium soaps in the
peritoneal cavity (saponification), causing hypocalcemia. This is a poor prognostic sign.
💫ANSWER✔️✔️: B) Saponification of calcium in the abdomen
---
7. A patient with a history of COPD has an oxygen saturation of 88% on 2 L/min nasal cannula. The
patient is alert and oriented. What is the priority action?
A) Increase oxygen to 4 L/min
B) Document the finding as expected
C) Obtain an arterial blood gas
D) Apply a non-rebreather mask at 15 L/min
💫RATIONALE✔️✔️: Target SpO2 for COPD is 88-92% to maintain hypoxic drive. 88% is acceptable.
Increasing oxygen can cause hypercapnia and respiratory depression.
💫ANSWER✔️✔️: B) Document the finding as expected
---
8. A patient with a new diagnosis of heart failure is being discharged. Which instruction is most
important to prevent readmission?
A) "Weigh yourself daily and report a gain of 2-3 pounds in 24 hours."
, B) "Limit your fluid intake to 1.5 liters per day."
C) "Exercise for 30 minutes daily even if you feel short of breath."
D) "Take your furosemide only when you feel swollen."
💫RATIONALE✔️✔️: Daily weight monitoring is the most sensitive indicator of fluid retention. A rapid
weight gain (2-3 lbs in 24 hours) indicates worsening heart failure and requires intervention. Do not skip
diuretics.
💫ANSWER✔️✔️: A) "Weigh yourself daily and report a gain of 2-3 pounds in 24 hours."
---
9. A patient with a history of cirrhosis is admitted with hematemesis. The nurse prepares for which
emergent procedure?
A) Endoscopic variceal ligation
B) Paracentesis
C) Transjugular intrahepatic portosystemic shunt (TIPS)
D) Balloon tamponade with a Minnesota tube
💫RATIONALE✔️✔️: Hematemesis in cirrhosis suggests esophageal variceal bleed. Emergent endoscopy
with band ligation is first-line. Balloon tamponade is rescue if endoscopy fails or unavailable.
💫ANSWER✔️✔️: A) Endoscopic variceal ligation
---
10. A patient with chronic kidney disease is on hemodialysis. Which laboratory value is most important
to monitor for medication dosing?
A) Serum creatinine
B) Blood urea nitrogen (BUN)
C) Serum albumin
D) Electrolytes
💫RATIONALE✔️✔️: Many medications are renally cleared and require dose adjustment based on
estimated glomerular filtration rate (eGFR) or creatinine clearance. Serum creatinine is used to calculate
eGFR.
💫ANSWER✔️✔️: A) Serum creatinine
Surgical Nursing Certification**
1. A patient with chronic heart failure has a weight gain of 5 pounds in 3 days, crackles in the lung bases,
and 2+ pitting edema. Which intervention should the nurse implement first?
A) Restrict oral fluids to 1,000 mL/day
B) Administer furosemide 40 mg IV
C) Elevate the patient's legs above heart level
D) Insert an indwelling urinary catheter
💫RATIONALE✔️✔️: The patient is in acute decompensated heart failure with fluid overload. IV
furosemide rapidly reduces preload and relieves pulmonary congestion. Fluid restriction is important
but not first.
💫ANSWER✔️✔️: B) Administer furosemide 40 mg IV
---
2. A patient with cirrhosis has an ammonia level of 120 mcg/dL and is becoming increasingly confused.
Which medication order should the nurse question?
A) Lactulose 30 mL PO every 6 hours
B) Rifaximin 550 mg PO BID
C) Lorazepam 1 mg IV for agitation
D) Normal saline at 100 mL/hr
💫RATIONALE✔️✔️: Benzodiazepines (lorazepam) are metabolized by the liver and can precipitate or
worsen hepatic encephalopathy. Avoid sedatives in acute liver failure. Lactulose and rifaximin are
standard.
💫ANSWER✔️✔️: C) Lorazepam 1 mg IV for agitation
---
,3. A patient with a new diagnosis of type 1 diabetes is learning to self-administer insulin. The patient
draws up 20 units of NPH insulin, then 10 units of regular insulin in the same syringe. Which action is
incorrect?
A) Injecting air into the NPH vial first
B) Injecting air into the regular vial second
C) Drawing up the regular insulin first
D) Drawing up the NPH insulin first
💫RATIONALE✔️✔️: When mixing insulins, draw up the clear (regular) first, then the cloudy (NPH).
Drawing up NPH first contaminates the regular vial. The air injection order is into NPH first, then regular.
💫ANSWER✔️✔️: D) Drawing up the NPH insulin first
---
4. A patient with a deep vein thrombosis (DVT) is on a heparin drip. The aPTT is 45 seconds (goal 60-80).
What is the priority action?
A) Increase the heparin drip rate per protocol
B) Administer a heparin bolus of 80 units/kg
C) Draw aPTT in 6 hours
D) Notify the provider of subtherapeutic level
💫RATIONALE✔️✔️: Subtherapeutic aPTT requires an increase in infusion rate per nomogram. Many
nomograms also include a bolus if aPTT is significantly low. Increase rate and consider bolus.
💫ANSWER✔️✔️: A) Increase the heparin drip rate per protocol
---
5. A patient with chronic kidney disease (CKD) has a potassium level of 6.2 mEq/L. The ECG shows
peaked T waves. What is the priority action?
A) Administer sodium polystyrene sulfonate (Kayexalate)
B) Administer calcium gluconate 1 g IV
C) Administer insulin 10 units IV with dextrose 25 g IV
D) Prepare for hemodialysis
,💫RATIONALE✔️✔️: Hyperkalemia with ECG changes requires immediate cardiac membrane stabilization
with IV calcium gluconate. Then shift potassium with insulin/dextrose. Kayexalate and dialysis remove
potassium but are not first for emergency stabilization.
💫ANSWER✔️✔️: B) Administer calcium gluconate 1 g IV
---
6. A patient with pancreatitis has a calcium level of 6.8 mg/dL. Which finding is most likely the cause?
A) Hypoalbuminemia
B) Saponification of calcium in the abdomen
C) Malabsorption of vitamin D
D) Hyperparathyroidism
💫RATIONALE✔️✔️: In acute pancreatitis, free fatty acids bind to calcium, forming calcium soaps in the
peritoneal cavity (saponification), causing hypocalcemia. This is a poor prognostic sign.
💫ANSWER✔️✔️: B) Saponification of calcium in the abdomen
---
7. A patient with a history of COPD has an oxygen saturation of 88% on 2 L/min nasal cannula. The
patient is alert and oriented. What is the priority action?
A) Increase oxygen to 4 L/min
B) Document the finding as expected
C) Obtain an arterial blood gas
D) Apply a non-rebreather mask at 15 L/min
💫RATIONALE✔️✔️: Target SpO2 for COPD is 88-92% to maintain hypoxic drive. 88% is acceptable.
Increasing oxygen can cause hypercapnia and respiratory depression.
💫ANSWER✔️✔️: B) Document the finding as expected
---
8. A patient with a new diagnosis of heart failure is being discharged. Which instruction is most
important to prevent readmission?
A) "Weigh yourself daily and report a gain of 2-3 pounds in 24 hours."
, B) "Limit your fluid intake to 1.5 liters per day."
C) "Exercise for 30 minutes daily even if you feel short of breath."
D) "Take your furosemide only when you feel swollen."
💫RATIONALE✔️✔️: Daily weight monitoring is the most sensitive indicator of fluid retention. A rapid
weight gain (2-3 lbs in 24 hours) indicates worsening heart failure and requires intervention. Do not skip
diuretics.
💫ANSWER✔️✔️: A) "Weigh yourself daily and report a gain of 2-3 pounds in 24 hours."
---
9. A patient with a history of cirrhosis is admitted with hematemesis. The nurse prepares for which
emergent procedure?
A) Endoscopic variceal ligation
B) Paracentesis
C) Transjugular intrahepatic portosystemic shunt (TIPS)
D) Balloon tamponade with a Minnesota tube
💫RATIONALE✔️✔️: Hematemesis in cirrhosis suggests esophageal variceal bleed. Emergent endoscopy
with band ligation is first-line. Balloon tamponade is rescue if endoscopy fails or unavailable.
💫ANSWER✔️✔️: A) Endoscopic variceal ligation
---
10. A patient with chronic kidney disease is on hemodialysis. Which laboratory value is most important
to monitor for medication dosing?
A) Serum creatinine
B) Blood urea nitrogen (BUN)
C) Serum albumin
D) Electrolytes
💫RATIONALE✔️✔️: Many medications are renally cleared and require dose adjustment based on
estimated glomerular filtration rate (eGFR) or creatinine clearance. Serum creatinine is used to calculate
eGFR.
💫ANSWER✔️✔️: A) Serum creatinine
