Medical-Surgical Nursing Certification (MEDSURG-BC™) Examination Practice Question Bank
V2.0: Advanced Clinical Scenarios, Multisystem Integration, and Complex Decision-Making for
Expert Medical-Surgical Nursing Practice
Instructions
This advanced practice question bank contains 150 multiple-choice questions designed to simulate the ANCC MEDSURG-BC certification examination at
the expert level. Questions are written for experienced medical-surgical nurses seeking board certification and require integrative clinical
reasoning, multisystem analysis, and complex prioritization.
Exam Blueprint (ANCC Test Content Outline):
Assessment and Diagnosis – 39% of scored items
Planning, Implementation, and Evaluation – 40% of scored items
Professional Role – 21% of scored items
Question Characteristics:
High-complexity clinical scenarios
Multisystem pathophysiology integration
Pharmacological and non-pharmacological interventions
Ethical, legal, and professional practice considerations
Evidence-based practice application
Each question includes:
One correct answer
Detailed rationale with pathophysiology integration
Analysis of each distractor
SECTION 1: ASSESSMENT AND DIAGNOSIS (Questions 1–58)
Cardiovascular System
1. A 74-year-old male with a history of ischemic cardiomyopathy (EF 25%), chronic kidney disease stage 3b (eGFR 38 mL/min/1.73m²), and type 2
diabetes mellitus presents to the emergency department with progressive dyspnea on exertion, orthopnea requiring four pillows, and a 6-pound
weight gain over 4 days. Vital signs: BP 148/92 mmHg, HR 112 bpm (irregularly irregular), RR 26/min, SpO2 90% on 2 L/min nasal cannula, afebrile.
Physical examination reveals jugular venous distention at 45 degrees, S3 gallop, coarse crackles to mid-scapulae bilaterally, 3+ pitting edema to the
knees, and a tender, palpable liver edge 4 cm below the costal margin. ECG shows atrial fibrillation with rapid ventricular response. Chest X-ray
demonstrates cardiomegaly, pulmonary vascular congestion, and small bilateral pleural effusions. Which laboratory finding, if present, would MOST
significantly alter the immediate management strategy for this patient's acute decompensated heart failure?
A. Serum troponin I 0.08 ng/mL (reference < 0.04 ng/mL)
B. Serum creatinine 2.1 mg/dL (baseline 1.6 mg/dL)
C. Serum potassium 5.9 mEq/L
D. B-type natriuretic peptide 1,850 pg/mL
Correct Answer: C
Rationale: A potassium of 5.9 mEq/L represents severe hyperkalemia that significantly alters immediate management. This patient is in acute
decompensated heart failure with atrial fibrillation, likely on ACE inhibitors, aldosterone antagonists, and possibly digoxin. Hyperkalemia is a life-
threatening electrolyte disturbance that requires emergent intervention (calcium gluconate for myocardial stabilization, insulin/glucose, albuterol,
kayexalate, or hemodialysis) and may preclude the use of standard HF therapies (e.g., ACE inhibitors, aldosterone antagonists). Troponin elevation (A) of
0.08 ng/mL may indicate type 2 myocardial injury (supply/demand mismatch) but is not immediately life-altering in management compared to
hyperkalemia. Creatinine elevation (B) of 2.1 mg/dL (increase of 0.5 mg/dL) indicates acute kidney injury (prerenal versus intrinsic) but does not
immediately change the management as aggressively as hyperkalemia. BNP elevation (D) confirms heart failure but is expected and does not alter
immediate management.
,2. A 62-year-old female with a 30-pack-year smoking history, hyperlipidemia, and hypertension presents with acute-onset chest pain described as
"tearing" in quality, radiating to the interscapular region, accompanied by diaphoresis and nausea. Vital signs: BP 184/102 mmHg in the right arm,
98/64 mmHg in the left arm, HR 118 bpm, RR 22/min, SpO2 96% on room air. Physical examination reveals a diastolic murmur at the left sternal border,
diminished left radial pulse, and a neurological examination notable for left-sided weakness. ECG demonstrates sinus tachycardia with no ischemic
changes. Chest X-ray shows a widened mediastinum. What is the PRIORITY nursing action while awaiting the STAT computed tomography
angiography?
A. Administer sublingual nitroglycerin 0.4 mg for blood pressure control
B. Administer IV metoprolol 5 mg to lower heart rate and blood pressure
C. Administer IV morphine 4 mg for pain management
D. Administer IV labetalol 20 mg and maintain systolic BP 100–120 mmHg
Correct Answer: D
Rationale: This patient is presenting with an acute aortic dissection (classic tearing chest pain radiating to the back, pulse differential, widened
mediastinum, neurological deficit). The priority is aggressive blood pressure and heart rate control to reduce shear stress and prevent propagation of the
dissection. Labetalol (a combined alpha-beta blocker) is preferred for its rapid onset and ability to reduce both blood pressure and heart rate, targeting
systolic BP 100–120 mmHg. Nitroglycerin (A) is primarily a venous vasodilator and can cause reflex tachycardia, which is detrimental as increased heart rate
increases shear stress. Metoprolol (B) alone at 5 mg IV may be insufficient for urgent blood pressure control. Morphine (C) addresses pain but does not
address the underlying hemodynamic emergency; pain management is important but secondary to aggressive hemodynamic control.
3. A 58-year-old male with ischemic cardiomyopathy (EF 30%) and a biventricular implantable cardioverter-defibrillator (CRT-D) is admitted with
progressive heart failure symptoms. His home medications include carvedilol 25 mg twice daily, lisinopril 20 mg daily, spironolactone 25 mg daily,
furosemide 80 mg twice daily, and digoxin 0.125 mg daily. In the past 24 hours, he has gained 4 pounds, has increased dyspnea, and his spironolactone
was increased to 50 mg daily. This morning, his laboratory results show: sodium 134 mEq/L, potassium 5.7 mEq/L, BUN 48 mg/dL, creatinine 2.0
mg/dL, and digoxin level 1.8 ng/mL. Which intervention should the nurse implement FIRST?
A. Hold the digoxin and prepare to administer digoxin immune Fab
B. Hold the spironolactone and notify the provider of the potassium level
C. Administer sodium polystyrene sulfonate (Kayexalate) 30 g orally
D. Administer IV insulin with 50% dextrose and nebulized albuterol
Correct Answer: B
Rationale: The priority is addressing the hyperkalemia (5.7 mEq/L) by holding the spironolactone (an aldosterone antagonist that can cause potassium
retention). Spironolactone is the most likely cause of the rising potassium in this patient with CKD and recent dose increase. While potassium 5.7 mEq/L
requires intervention, it is not immediately life-threatening (unlike > 6.0–6.5 mEq/L with ECG changes), so the first step is to remove the offending agent.
Digoxin level 1.8 ng/mL is within the therapeutic range (0.8–2.0 ng/mL), so digoxin immune Fab (A) is not indicated. Sodium polystyrene sulfonate (C) and
insulin/albuterol (D) are interventions for hyperkalemia but the immediate priority is identifying and removing the cause.
4. A 48-year-old female with no significant medical history presents with progressive dyspnea on exertion, fatigue, and palpitations over the past 6
months. She reports a recent diagnosis of "heart failure" by an outside provider but has not followed up. Physical examination reveals a systolic
ejection murmur at the right upper sternal border that radiates to the carotids, a diminished S2, and a delayed carotid upstroke. Jugular venous
pressure is estimated at 14 cm H₂O with prominent A waves. ECG demonstrates left ventricular hypertrophy with strain pattern. Echocardiography
reveals a peak gradient of 80 mmHg across the aortic valve, aortic valve area of 0.8 cm², and left ventricular ejection fraction of 55%. Which nursing
assessment finding would be MOST concerning for this patient's immediate prognosis?
A. New-onset atrial fibrillation with ventricular rate of 140 bpm
B. Syncope occurring with exertion
C. Chest pain radiating to the left arm
D. Orthopnea requiring three pillows
Correct Answer: B
Rationale: This patient has severe aortic stenosis (peak gradient > 40 mmHg, valve area < 1.0 cm²). Syncope with exertion is a classic and ominous
symptom in aortic stenosis that indicates severe obstruction with inability to increase cardiac output during stress. Exertional syncope in aortic stenosis
carries a poor prognosis and is an indication for urgent valve replacement. Atrial fibrillation (A) is concerning but can be managed medically and is less
immediately ominous than exertional syncope. Chest pain (C) in aortic stenosis may indicate angina from myocardial ischemia due to LV hypertrophy and is
concerning but not as prognostically ominous as exertional syncope. Orthopnea (D) indicates heart failure but is a later finding and less immediately
ominous than exertional syncope.
5. A 55-year-old male with a history of hypertension, hyperlipidemia, and type 2 diabetes presents with acute-onset substernal chest pain that is
"pressure-like," radiating to the left arm, associated with diaphoresis and nausea. Symptoms began 90 minutes ago. Emergency medical services
administered aspirin 324 mg chewed and sublingual nitroglycerin 0.4 mg x 2 with partial relief. ECG in the emergency department reveals ST-segment
elevation of 3 mm in leads V1–V4 with reciprocal changes in leads II, III, and aVF. Vital signs: BP 138/84 mmHg, HR 96 bpm, RR 18/min, SpO2 97% on
,room air. The patient is a candidate for percutaneous coronary intervention. Which finding on the pre-procedure history and physical examination
would be an ABSOLUTE contraindication to the administration of a P2Y12 inhibitor (clopidogrel or ticagrelor)?
A. History of peptic ulcer disease with recent gastrointestinal bleeding
B. Hemoglobin of 10.2 g/dL with a platelet count of 145,000/mm³
C. History of intracranial hemorrhage 4 months ago
D. Serum creatinine of 2.5 mg/dL (baseline 1.0 mg/dL)
Correct Answer: C
Rationale: History of intracranial hemorrhage is an absolute contraindication to P2Y12 inhibitors (clopidogrel, ticagrelor) due to the risk of rebleeding. The
4-month timeframe is too recent (typically, any ICH in the past year is a contraindication). Peptic ulcer disease with recent bleeding (A) is a relative, not
absolute, contraindication; the benefit of P2Y12 inhibition in STEMI may outweigh the risk, and the patient can receive concomitant PPI therapy.
Thrombocytopenia with platelet count 145,000 (B) is not an absolute contraindication; a platelet count > 100,000 is generally acceptable. Creatinine 2.5 (D)
is not a contraindication to P2Y12 inhibitors; it is a relative contraindication to enoxaparin but not to antiplatelet agents.
6. A 72-year-old female with heart failure with preserved ejection fraction (HFpEF), hypertension, and chronic atrial fibrillation is admitted with acute
pulmonary edema. Her home medications include warfarin (INR therapeutic 2.5), amlodipine, and furosemide. In the emergency department, she is
given IV furosemide 80 mg and IV nitroglycerin. She is now in the intensive care unit on continuous positive airway pressure (CPAP). Her urine output
over the past 2 hours is 40 mL. Vital signs: BP 102/58 mmHg, HR 82 bpm, RR 22/min, SpO2 96% on 50% FiO2 via CPAP. Physical examination reveals
JVP 16 cm H₂O, crackles in bilateral lung bases, and 2+ pitting edema in the lower extremities. The provider orders IV furosemide 40 mg. Which
assessment parameter should the nurse evaluate to determine the OPTIMAL timing and effectiveness of the furosemide administration?
A. The patient's daily weight compared to admission weight
B. The patient's urine output in the first 30–60 minutes after furosemide administration
C. The patient's serum creatinine and BUN levels
D. The patient's jugular venous pressure and crackles on pulmonary auscultation
Correct Answer: B
Rationale: In acute decompensated heart failure, the optimal timing of loop diuretic administration is guided by the patient's response. Evaluating urine
output in the first 30–60 minutes after furosemide administration is the most immediate and direct measure of diuretic effectiveness and renal perfusion.
Daily weight (A) is too long-term. Creatinine/BUN (C) indicate renal function but do not provide immediate feedback on diuretic response. JVP and crackles
(D) indicate volume status but are less sensitive to acute diuretic response than urine output.
7. A 66-year-old male with a history of non-ST-segment elevation myocardial infarction 3 years ago, hypertension, and hyperlipidemia presents with
progressive fatigue and dyspnea over the past 2 months. He reports a "heavy" sensation in his chest with exertion that resolves with rest.
Echocardiography demonstrates severe aortic stenosis (valve area 0.7 cm²) with a mean gradient of 55 mmHg, left ventricular hypertrophy, and an
ejection fraction of 60%. The patient is scheduled for transcatheter aortic valve replacement. He is currently on aspirin 81 mg daily, clopidogrel 75 mg
daily, atorvastatin 40 mg daily, and lisinopril 10 mg daily. Which medication should the nurse anticipate will be DISCONTINUED before the TAVR
procedure, and for how long?
A. Atorvastatin 40 mg daily—discontinue 5 days before procedure
B. Lisinopril 10 mg daily—discontinue 24 hours before procedure
C. Clopidogrel 75 mg daily—discontinue 5 days before procedure (if not undergoing TAVR with dual antiplatelet therapy)
D. Aspirin 81 mg daily—discontinue 7 days before procedure
Correct Answer: C
Rationale: For patients undergoing TAVR, clopidogrel (a P2Y12 inhibitor) should be held for 5 days before the procedure unless the patient is undergoing
TAVR with planned dual antiplatelet therapy (which is typically used after the procedure, not before). Aspirin (D) is generally continued. Atorvastatin (A)
does not need to be discontinued (it may be continued) for TAVR. Lisinopril (B) is typically continued (or held per anesthesia protocol) but does not have a
specific 24-hour hold requirement.
8. A 49-year-old female with systemic lupus erythematosus presents with pleuritic chest pain, fever, and a pericardial friction rub. ECG demonstrates
diffuse ST-segment elevation and PR-segment depression. Echocardiography reveals a moderate pericardial effusion. Which additional finding would
suggest that the effusion is likely to require urgent pericardiocentesis?
A. Diastolic collapse of the right ventricle on echocardiography
B. International normalized ratio (INR) of 2.5 (patient on warfarin for mechanical mitral valve)
C. White blood cell count of 14,000/mm³
D. Pericardial fluid glucose < 30 mg/dL
Correct Answer: A
, Rationale: Echocardiographic evidence of right ventricular diastolic collapse is a sign of cardiac tamponade and indicates the need for urgent
pericardiocentesis. An INR of 2.5 (B) is therapeutic and does not directly indicate the need for pericardiocentesis; it complicates the procedure but does not
indicate tamponade. White blood cell count (C) indicates infection but does not indicate tamponade. Pericardial fluid glucose < 30 mg/dL (D) suggests
infection or malignancy but does not indicate the need for urgent pericardiocentesis.
9. A 58-year-old male with a history of hypertension, type 2 diabetes, and chronic kidney disease (stage 3b) presents with progressive dyspnea on
exertion, fatigue, and a 10-pound weight gain over 2 weeks. He reports increasing abdominal girth and ankle swelling. Vital signs: BP 152/94 mmHg,
HR 92 bpm, RR 22/min, SpO2 94% on room air. Physical examination reveals jugular venous distention, an S3 gallop, bilateral crackles up to the mid-
thorax, hepatomegaly, and 3+ pitting edema to the knees. Echocardiography demonstrates a left ventricular ejection fraction of 25% with severe mitral
regurgitation. He is diagnosed with acute decompensated heart failure. His serum creatinine has increased from 1.5 mg/dL (baseline) to 2.2 mg/dL.
Which of the following interventions, if initiated, would MOST likely worsen his renal function?
A. IV furosemide 40 mg bolus
B. IV nitroglycerin 50 mcg/min
C. IV hydralazine 10 mg and isosorbide dinitrate 5 mg
D. IV dobutamine 5 mcg/kg/min
Correct Answer: A
Rationale: IV furosemide can worsen renal function through a combination of hemodynamic effects (decreased renal perfusion) and direct tubular toxicity.
In a patient with worsening renal function (creatinine increasing from 1.5 to 2.2 mg/dL) and acute decompensated HF, aggressive diuresis may cause
further prerenal azotemia. Nitroglycerin (B) is a vasodilator that may improve renal perfusion. Hydralazine/isosorbide (C) may improve renal perfusion by
reducing afterload and increasing cardiac output. Dobutamine (D) is an inotrope that may improve renal perfusion by increasing cardiac output.
10. A 65-year-old female with a history of non-Hodgkin's lymphoma (in remission), hypertension, and hyperlipidemia presents with sudden-onset
severe headache, chest pain, and a "tearing" sensation in her back. The pain radiates to her abdomen. Vital signs: BP 210/120 mmHg in the right arm,
180/110 mmHg in the left arm, HR 104 bpm, RR 20/min, SpO2 98% on room air. Physical examination reveals a 2/6 diastolic murmur at the left sternal
border and a neurological examination with a right-sided visual field deficit. ECG shows sinus tachycardia with no ischemic changes. A STAT computed
tomography angiography of the chest, abdomen, and pelvis confirms an acute aortic dissection starting at the aortic root and extending to the
descending aorta. Which immediate nursing intervention is the HIGHEST priority?
A. Administer IV labetalol 20 mg and maintain systolic blood pressure 100–120 mmHg
B. Administer IV sodium nitroprusside and maintain systolic blood pressure 80–100 mmHg
C. Administer IV morphine 4 mg for pain control
D. Prepare the patient for immediate surgical repair
Correct Answer: A
Rationale: The highest priority is aggressive blood pressure control with a beta-blocker (labetalol) to reduce the force of left ventricular ejection and
decrease aortic wall stress, preventing propagation of the dissection. The target systolic blood pressure is 100–120 mmHg. Nitroprusside (B) is a vasodilator
that reduces blood pressure but can cause reflex tachycardia (increase in dP/dt) without beta-blockade, which increases shear stress; it should be used with
a beta-blocker, not alone. Morphine (C) is important for pain but does not address the hemodynamic emergency. Surgical repair (D) is typically indicated
for type A (ascending) dissections; this patient has a type A dissection but the priority is blood pressure control before surgery.
Respiratory System
11. A 72-year-old male with a 60-pack-year smoking history and severe COPD (GOLD stage 4, FEV1 28% predicted) presents with increasing shortness
of breath, cough, and purulent sputum production for 5 days. He reports increased use of his home nebulized albuterol with minimal relief. Vital signs:
BP 142/86 mmHg, HR 110 bpm, RR 30/min, SpO2 86% on 2 L/min nasal cannula, temperature 38.2°C. Physical examination reveals distant breath
sounds, expiratory wheezing, and 2+ pitting edema in the lower extremities. Arterial blood gas on 2 L/min oxygen: pH 7.29, PaCO2 68 mmHg, PaO2 54
mmHg, HCO3 32 mEq/L. The patient is started on non-invasive positive pressure ventilation (NIV). Which finding, if present, would be the STRONGEST
indication for intubation and mechanical ventilation?
A. pH 7.28 (decrease from 7.30 on admission)
B. PaCO2 72 mmHg (increase from 65 mmHg on admission)
C. Persistent respiratory rate 32/min despite NIV
D. Inability to clear secretions and worsening mental status (GCS 10)
Correct Answer: D
Rationale: Inability to protect the airway (worsening mental status with GCS 10) and inability to clear secretions are absolute indications for intubation in
acute respiratory failure. While a rising PaCO2 (B) and decreasing pH (A) are concerning, they are not absolute indications for intubation if the patient can
still protect their airway and tolerate NIV. Persistent tachypnea (C) is a sign of respiratory fatigue but is not an absolute indication for intubation if the
patient is still managing airway protection.
V2.0: Advanced Clinical Scenarios, Multisystem Integration, and Complex Decision-Making for
Expert Medical-Surgical Nursing Practice
Instructions
This advanced practice question bank contains 150 multiple-choice questions designed to simulate the ANCC MEDSURG-BC certification examination at
the expert level. Questions are written for experienced medical-surgical nurses seeking board certification and require integrative clinical
reasoning, multisystem analysis, and complex prioritization.
Exam Blueprint (ANCC Test Content Outline):
Assessment and Diagnosis – 39% of scored items
Planning, Implementation, and Evaluation – 40% of scored items
Professional Role – 21% of scored items
Question Characteristics:
High-complexity clinical scenarios
Multisystem pathophysiology integration
Pharmacological and non-pharmacological interventions
Ethical, legal, and professional practice considerations
Evidence-based practice application
Each question includes:
One correct answer
Detailed rationale with pathophysiology integration
Analysis of each distractor
SECTION 1: ASSESSMENT AND DIAGNOSIS (Questions 1–58)
Cardiovascular System
1. A 74-year-old male with a history of ischemic cardiomyopathy (EF 25%), chronic kidney disease stage 3b (eGFR 38 mL/min/1.73m²), and type 2
diabetes mellitus presents to the emergency department with progressive dyspnea on exertion, orthopnea requiring four pillows, and a 6-pound
weight gain over 4 days. Vital signs: BP 148/92 mmHg, HR 112 bpm (irregularly irregular), RR 26/min, SpO2 90% on 2 L/min nasal cannula, afebrile.
Physical examination reveals jugular venous distention at 45 degrees, S3 gallop, coarse crackles to mid-scapulae bilaterally, 3+ pitting edema to the
knees, and a tender, palpable liver edge 4 cm below the costal margin. ECG shows atrial fibrillation with rapid ventricular response. Chest X-ray
demonstrates cardiomegaly, pulmonary vascular congestion, and small bilateral pleural effusions. Which laboratory finding, if present, would MOST
significantly alter the immediate management strategy for this patient's acute decompensated heart failure?
A. Serum troponin I 0.08 ng/mL (reference < 0.04 ng/mL)
B. Serum creatinine 2.1 mg/dL (baseline 1.6 mg/dL)
C. Serum potassium 5.9 mEq/L
D. B-type natriuretic peptide 1,850 pg/mL
Correct Answer: C
Rationale: A potassium of 5.9 mEq/L represents severe hyperkalemia that significantly alters immediate management. This patient is in acute
decompensated heart failure with atrial fibrillation, likely on ACE inhibitors, aldosterone antagonists, and possibly digoxin. Hyperkalemia is a life-
threatening electrolyte disturbance that requires emergent intervention (calcium gluconate for myocardial stabilization, insulin/glucose, albuterol,
kayexalate, or hemodialysis) and may preclude the use of standard HF therapies (e.g., ACE inhibitors, aldosterone antagonists). Troponin elevation (A) of
0.08 ng/mL may indicate type 2 myocardial injury (supply/demand mismatch) but is not immediately life-altering in management compared to
hyperkalemia. Creatinine elevation (B) of 2.1 mg/dL (increase of 0.5 mg/dL) indicates acute kidney injury (prerenal versus intrinsic) but does not
immediately change the management as aggressively as hyperkalemia. BNP elevation (D) confirms heart failure but is expected and does not alter
immediate management.
,2. A 62-year-old female with a 30-pack-year smoking history, hyperlipidemia, and hypertension presents with acute-onset chest pain described as
"tearing" in quality, radiating to the interscapular region, accompanied by diaphoresis and nausea. Vital signs: BP 184/102 mmHg in the right arm,
98/64 mmHg in the left arm, HR 118 bpm, RR 22/min, SpO2 96% on room air. Physical examination reveals a diastolic murmur at the left sternal border,
diminished left radial pulse, and a neurological examination notable for left-sided weakness. ECG demonstrates sinus tachycardia with no ischemic
changes. Chest X-ray shows a widened mediastinum. What is the PRIORITY nursing action while awaiting the STAT computed tomography
angiography?
A. Administer sublingual nitroglycerin 0.4 mg for blood pressure control
B. Administer IV metoprolol 5 mg to lower heart rate and blood pressure
C. Administer IV morphine 4 mg for pain management
D. Administer IV labetalol 20 mg and maintain systolic BP 100–120 mmHg
Correct Answer: D
Rationale: This patient is presenting with an acute aortic dissection (classic tearing chest pain radiating to the back, pulse differential, widened
mediastinum, neurological deficit). The priority is aggressive blood pressure and heart rate control to reduce shear stress and prevent propagation of the
dissection. Labetalol (a combined alpha-beta blocker) is preferred for its rapid onset and ability to reduce both blood pressure and heart rate, targeting
systolic BP 100–120 mmHg. Nitroglycerin (A) is primarily a venous vasodilator and can cause reflex tachycardia, which is detrimental as increased heart rate
increases shear stress. Metoprolol (B) alone at 5 mg IV may be insufficient for urgent blood pressure control. Morphine (C) addresses pain but does not
address the underlying hemodynamic emergency; pain management is important but secondary to aggressive hemodynamic control.
3. A 58-year-old male with ischemic cardiomyopathy (EF 30%) and a biventricular implantable cardioverter-defibrillator (CRT-D) is admitted with
progressive heart failure symptoms. His home medications include carvedilol 25 mg twice daily, lisinopril 20 mg daily, spironolactone 25 mg daily,
furosemide 80 mg twice daily, and digoxin 0.125 mg daily. In the past 24 hours, he has gained 4 pounds, has increased dyspnea, and his spironolactone
was increased to 50 mg daily. This morning, his laboratory results show: sodium 134 mEq/L, potassium 5.7 mEq/L, BUN 48 mg/dL, creatinine 2.0
mg/dL, and digoxin level 1.8 ng/mL. Which intervention should the nurse implement FIRST?
A. Hold the digoxin and prepare to administer digoxin immune Fab
B. Hold the spironolactone and notify the provider of the potassium level
C. Administer sodium polystyrene sulfonate (Kayexalate) 30 g orally
D. Administer IV insulin with 50% dextrose and nebulized albuterol
Correct Answer: B
Rationale: The priority is addressing the hyperkalemia (5.7 mEq/L) by holding the spironolactone (an aldosterone antagonist that can cause potassium
retention). Spironolactone is the most likely cause of the rising potassium in this patient with CKD and recent dose increase. While potassium 5.7 mEq/L
requires intervention, it is not immediately life-threatening (unlike > 6.0–6.5 mEq/L with ECG changes), so the first step is to remove the offending agent.
Digoxin level 1.8 ng/mL is within the therapeutic range (0.8–2.0 ng/mL), so digoxin immune Fab (A) is not indicated. Sodium polystyrene sulfonate (C) and
insulin/albuterol (D) are interventions for hyperkalemia but the immediate priority is identifying and removing the cause.
4. A 48-year-old female with no significant medical history presents with progressive dyspnea on exertion, fatigue, and palpitations over the past 6
months. She reports a recent diagnosis of "heart failure" by an outside provider but has not followed up. Physical examination reveals a systolic
ejection murmur at the right upper sternal border that radiates to the carotids, a diminished S2, and a delayed carotid upstroke. Jugular venous
pressure is estimated at 14 cm H₂O with prominent A waves. ECG demonstrates left ventricular hypertrophy with strain pattern. Echocardiography
reveals a peak gradient of 80 mmHg across the aortic valve, aortic valve area of 0.8 cm², and left ventricular ejection fraction of 55%. Which nursing
assessment finding would be MOST concerning for this patient's immediate prognosis?
A. New-onset atrial fibrillation with ventricular rate of 140 bpm
B. Syncope occurring with exertion
C. Chest pain radiating to the left arm
D. Orthopnea requiring three pillows
Correct Answer: B
Rationale: This patient has severe aortic stenosis (peak gradient > 40 mmHg, valve area < 1.0 cm²). Syncope with exertion is a classic and ominous
symptom in aortic stenosis that indicates severe obstruction with inability to increase cardiac output during stress. Exertional syncope in aortic stenosis
carries a poor prognosis and is an indication for urgent valve replacement. Atrial fibrillation (A) is concerning but can be managed medically and is less
immediately ominous than exertional syncope. Chest pain (C) in aortic stenosis may indicate angina from myocardial ischemia due to LV hypertrophy and is
concerning but not as prognostically ominous as exertional syncope. Orthopnea (D) indicates heart failure but is a later finding and less immediately
ominous than exertional syncope.
5. A 55-year-old male with a history of hypertension, hyperlipidemia, and type 2 diabetes presents with acute-onset substernal chest pain that is
"pressure-like," radiating to the left arm, associated with diaphoresis and nausea. Symptoms began 90 minutes ago. Emergency medical services
administered aspirin 324 mg chewed and sublingual nitroglycerin 0.4 mg x 2 with partial relief. ECG in the emergency department reveals ST-segment
elevation of 3 mm in leads V1–V4 with reciprocal changes in leads II, III, and aVF. Vital signs: BP 138/84 mmHg, HR 96 bpm, RR 18/min, SpO2 97% on
,room air. The patient is a candidate for percutaneous coronary intervention. Which finding on the pre-procedure history and physical examination
would be an ABSOLUTE contraindication to the administration of a P2Y12 inhibitor (clopidogrel or ticagrelor)?
A. History of peptic ulcer disease with recent gastrointestinal bleeding
B. Hemoglobin of 10.2 g/dL with a platelet count of 145,000/mm³
C. History of intracranial hemorrhage 4 months ago
D. Serum creatinine of 2.5 mg/dL (baseline 1.0 mg/dL)
Correct Answer: C
Rationale: History of intracranial hemorrhage is an absolute contraindication to P2Y12 inhibitors (clopidogrel, ticagrelor) due to the risk of rebleeding. The
4-month timeframe is too recent (typically, any ICH in the past year is a contraindication). Peptic ulcer disease with recent bleeding (A) is a relative, not
absolute, contraindication; the benefit of P2Y12 inhibition in STEMI may outweigh the risk, and the patient can receive concomitant PPI therapy.
Thrombocytopenia with platelet count 145,000 (B) is not an absolute contraindication; a platelet count > 100,000 is generally acceptable. Creatinine 2.5 (D)
is not a contraindication to P2Y12 inhibitors; it is a relative contraindication to enoxaparin but not to antiplatelet agents.
6. A 72-year-old female with heart failure with preserved ejection fraction (HFpEF), hypertension, and chronic atrial fibrillation is admitted with acute
pulmonary edema. Her home medications include warfarin (INR therapeutic 2.5), amlodipine, and furosemide. In the emergency department, she is
given IV furosemide 80 mg and IV nitroglycerin. She is now in the intensive care unit on continuous positive airway pressure (CPAP). Her urine output
over the past 2 hours is 40 mL. Vital signs: BP 102/58 mmHg, HR 82 bpm, RR 22/min, SpO2 96% on 50% FiO2 via CPAP. Physical examination reveals
JVP 16 cm H₂O, crackles in bilateral lung bases, and 2+ pitting edema in the lower extremities. The provider orders IV furosemide 40 mg. Which
assessment parameter should the nurse evaluate to determine the OPTIMAL timing and effectiveness of the furosemide administration?
A. The patient's daily weight compared to admission weight
B. The patient's urine output in the first 30–60 minutes after furosemide administration
C. The patient's serum creatinine and BUN levels
D. The patient's jugular venous pressure and crackles on pulmonary auscultation
Correct Answer: B
Rationale: In acute decompensated heart failure, the optimal timing of loop diuretic administration is guided by the patient's response. Evaluating urine
output in the first 30–60 minutes after furosemide administration is the most immediate and direct measure of diuretic effectiveness and renal perfusion.
Daily weight (A) is too long-term. Creatinine/BUN (C) indicate renal function but do not provide immediate feedback on diuretic response. JVP and crackles
(D) indicate volume status but are less sensitive to acute diuretic response than urine output.
7. A 66-year-old male with a history of non-ST-segment elevation myocardial infarction 3 years ago, hypertension, and hyperlipidemia presents with
progressive fatigue and dyspnea over the past 2 months. He reports a "heavy" sensation in his chest with exertion that resolves with rest.
Echocardiography demonstrates severe aortic stenosis (valve area 0.7 cm²) with a mean gradient of 55 mmHg, left ventricular hypertrophy, and an
ejection fraction of 60%. The patient is scheduled for transcatheter aortic valve replacement. He is currently on aspirin 81 mg daily, clopidogrel 75 mg
daily, atorvastatin 40 mg daily, and lisinopril 10 mg daily. Which medication should the nurse anticipate will be DISCONTINUED before the TAVR
procedure, and for how long?
A. Atorvastatin 40 mg daily—discontinue 5 days before procedure
B. Lisinopril 10 mg daily—discontinue 24 hours before procedure
C. Clopidogrel 75 mg daily—discontinue 5 days before procedure (if not undergoing TAVR with dual antiplatelet therapy)
D. Aspirin 81 mg daily—discontinue 7 days before procedure
Correct Answer: C
Rationale: For patients undergoing TAVR, clopidogrel (a P2Y12 inhibitor) should be held for 5 days before the procedure unless the patient is undergoing
TAVR with planned dual antiplatelet therapy (which is typically used after the procedure, not before). Aspirin (D) is generally continued. Atorvastatin (A)
does not need to be discontinued (it may be continued) for TAVR. Lisinopril (B) is typically continued (or held per anesthesia protocol) but does not have a
specific 24-hour hold requirement.
8. A 49-year-old female with systemic lupus erythematosus presents with pleuritic chest pain, fever, and a pericardial friction rub. ECG demonstrates
diffuse ST-segment elevation and PR-segment depression. Echocardiography reveals a moderate pericardial effusion. Which additional finding would
suggest that the effusion is likely to require urgent pericardiocentesis?
A. Diastolic collapse of the right ventricle on echocardiography
B. International normalized ratio (INR) of 2.5 (patient on warfarin for mechanical mitral valve)
C. White blood cell count of 14,000/mm³
D. Pericardial fluid glucose < 30 mg/dL
Correct Answer: A
, Rationale: Echocardiographic evidence of right ventricular diastolic collapse is a sign of cardiac tamponade and indicates the need for urgent
pericardiocentesis. An INR of 2.5 (B) is therapeutic and does not directly indicate the need for pericardiocentesis; it complicates the procedure but does not
indicate tamponade. White blood cell count (C) indicates infection but does not indicate tamponade. Pericardial fluid glucose < 30 mg/dL (D) suggests
infection or malignancy but does not indicate the need for urgent pericardiocentesis.
9. A 58-year-old male with a history of hypertension, type 2 diabetes, and chronic kidney disease (stage 3b) presents with progressive dyspnea on
exertion, fatigue, and a 10-pound weight gain over 2 weeks. He reports increasing abdominal girth and ankle swelling. Vital signs: BP 152/94 mmHg,
HR 92 bpm, RR 22/min, SpO2 94% on room air. Physical examination reveals jugular venous distention, an S3 gallop, bilateral crackles up to the mid-
thorax, hepatomegaly, and 3+ pitting edema to the knees. Echocardiography demonstrates a left ventricular ejection fraction of 25% with severe mitral
regurgitation. He is diagnosed with acute decompensated heart failure. His serum creatinine has increased from 1.5 mg/dL (baseline) to 2.2 mg/dL.
Which of the following interventions, if initiated, would MOST likely worsen his renal function?
A. IV furosemide 40 mg bolus
B. IV nitroglycerin 50 mcg/min
C. IV hydralazine 10 mg and isosorbide dinitrate 5 mg
D. IV dobutamine 5 mcg/kg/min
Correct Answer: A
Rationale: IV furosemide can worsen renal function through a combination of hemodynamic effects (decreased renal perfusion) and direct tubular toxicity.
In a patient with worsening renal function (creatinine increasing from 1.5 to 2.2 mg/dL) and acute decompensated HF, aggressive diuresis may cause
further prerenal azotemia. Nitroglycerin (B) is a vasodilator that may improve renal perfusion. Hydralazine/isosorbide (C) may improve renal perfusion by
reducing afterload and increasing cardiac output. Dobutamine (D) is an inotrope that may improve renal perfusion by increasing cardiac output.
10. A 65-year-old female with a history of non-Hodgkin's lymphoma (in remission), hypertension, and hyperlipidemia presents with sudden-onset
severe headache, chest pain, and a "tearing" sensation in her back. The pain radiates to her abdomen. Vital signs: BP 210/120 mmHg in the right arm,
180/110 mmHg in the left arm, HR 104 bpm, RR 20/min, SpO2 98% on room air. Physical examination reveals a 2/6 diastolic murmur at the left sternal
border and a neurological examination with a right-sided visual field deficit. ECG shows sinus tachycardia with no ischemic changes. A STAT computed
tomography angiography of the chest, abdomen, and pelvis confirms an acute aortic dissection starting at the aortic root and extending to the
descending aorta. Which immediate nursing intervention is the HIGHEST priority?
A. Administer IV labetalol 20 mg and maintain systolic blood pressure 100–120 mmHg
B. Administer IV sodium nitroprusside and maintain systolic blood pressure 80–100 mmHg
C. Administer IV morphine 4 mg for pain control
D. Prepare the patient for immediate surgical repair
Correct Answer: A
Rationale: The highest priority is aggressive blood pressure control with a beta-blocker (labetalol) to reduce the force of left ventricular ejection and
decrease aortic wall stress, preventing propagation of the dissection. The target systolic blood pressure is 100–120 mmHg. Nitroprusside (B) is a vasodilator
that reduces blood pressure but can cause reflex tachycardia (increase in dP/dt) without beta-blockade, which increases shear stress; it should be used with
a beta-blocker, not alone. Morphine (C) is important for pain but does not address the hemodynamic emergency. Surgical repair (D) is typically indicated
for type A (ascending) dissections; this patient has a type A dissection but the priority is blood pressure control before surgery.
Respiratory System
11. A 72-year-old male with a 60-pack-year smoking history and severe COPD (GOLD stage 4, FEV1 28% predicted) presents with increasing shortness
of breath, cough, and purulent sputum production for 5 days. He reports increased use of his home nebulized albuterol with minimal relief. Vital signs:
BP 142/86 mmHg, HR 110 bpm, RR 30/min, SpO2 86% on 2 L/min nasal cannula, temperature 38.2°C. Physical examination reveals distant breath
sounds, expiratory wheezing, and 2+ pitting edema in the lower extremities. Arterial blood gas on 2 L/min oxygen: pH 7.29, PaCO2 68 mmHg, PaO2 54
mmHg, HCO3 32 mEq/L. The patient is started on non-invasive positive pressure ventilation (NIV). Which finding, if present, would be the STRONGEST
indication for intubation and mechanical ventilation?
A. pH 7.28 (decrease from 7.30 on admission)
B. PaCO2 72 mmHg (increase from 65 mmHg on admission)
C. Persistent respiratory rate 32/min despite NIV
D. Inability to clear secretions and worsening mental status (GCS 10)
Correct Answer: D
Rationale: Inability to protect the airway (worsening mental status with GCS 10) and inability to clear secretions are absolute indications for intubation in
acute respiratory failure. While a rising PaCO2 (B) and decreasing pH (A) are concerning, they are not absolute indications for intubation if the patient can
still protect their airway and tolerate NIV. Persistent tachypnea (C) is a sign of respiratory fatigue but is not an absolute indication for intubation if the
patient is still managing airway protection.
