Comprehensive Medical-Surgical Nursing Prac ce Exam
NCLEX-Style Applica on & Analysis Ques ons
Ques on 1: Acute Respiratory Distress
Clinical Scenario: A 68-year-old pa ent with a history of chronic obstruc ve pulmonary
disease (COPD) is admi ed with pneumonia. The pa ent is restless, anxious, and reports
increasing shortness of breath. Vital signs: HR 118 bpm, RR 36 bpm, BP 148/88 mmHg,
SpO2 88% on 2 L/min nasal cannula. Ausculta on reveals coarse crackles in the right
lower lobe and diminished breath sounds throughout.
Ques on Stem: Which ac on should the nurse take first?
Op ons:
A. Administer the prescribed PRN albuterol nebulizer treatment.
B. Reposi on the pa ent to a high-Fowler's posi on.
C. Prepare for immediate endotracheal intuba on.
D. Increase the oxygen flow rate to 4 L/min via nasal cannula.
Answer and Ra onale
Correct Answer: B. Reposi on the pa ent to a high-Fowler's posi on.
Cogni ve Level: Applying
Client Needs Category: Physiological Adapta on
Main Lesson / Takeaway: The first ac on for a pa ent in respiratory distress is always to
posi on the airway for op mal ven la on.
Detailed Ra onale: The priority in any respiratory emergency is to ensure a patent
airway and maximize ven la on. High-Fowler's posi on uses gravity to lower the
diaphragm, allowing for greater lung expansion and improved gas exchange. This is a
rapid, non-invasive interven on that directly addresses the pa ent's hypoxia and
dyspnea. Op on A (albuterol) would be appropriate for bronchospasm, but it is a
treatment that takes me to administer and is not the immediate first step; posi oning
must occur first. Op on C (intuba on) is a poten al interven on if the pa ent fails to
respond to less invasive measures, but it is not the first ac on and carries significant
risks. Op on D (increasing oxygen) might be needed, but for a COPD pa ent, high-flow
oxygen can suppress the hypoxic drive, and reposi oning is a safer and more immediate
, ac on to improve mechanics before adjus ng oxygen. The immediate priority is to
op mize the pa ent's own physiological ability to breathe effec vely.
Ques on 2: Myocardial Infarc on Pharmacology
Clinical Scenario: A 72-year-old pa ent is brought to the emergency department with
crushing substernal chest pain radia ng to the jaw, nausea, and diaphoresis. An ECG
shows ST-segment eleva on in leads V1–V4. The pa ent's blood pressure is 90/62
mmHg, and heart rate is 48 bpm.
Ques on Stem: The nurse an cipates administering which medica on first?
Op ons:
A. Nitroglycerin 0.4 mg sublingual
B. Morphine sulfate 2 mg IV push
C. Atropine 0.5 mg IV push
D. Aspirin 324 mg chewable
Answer and Ra onale
Correct Answer: D. Aspirin 324 mg chewable
Cogni ve Level: Analyzing
Client Needs Category: Pharmacological and Parenteral Therapies
Main Lesson / Takeaway: In an acute STEMI, aspirin is the most cri cal and immediate
interven on to reduce mortality by preven ng further platelet aggrega on.
Detailed Ra onale: Aspirin is a cornerstone of acute MI management because it quickly
inhibits platelet aggrega on, preven ng the expansion of the exis ng thrombus. It is the
single most important medica on to administer immediately upon suspicion of an
MI. Op on A (Nitroglycerin) is a vasodilator that can be given for chest pain, but it is
rela vely contraindicated with a systolic BP <90 mmHg, as it could cause further
dangerous hypotension. Op on B (Morphine) is used for pain and to reduce preload, but
it is not the first priority over aspirin and can also cause vasodila on, worsening
hypotension in this pa ent. Op on C (Atropine) is used for symptoma c bradycardia,
but the primary and immediate therapy is aspirin to address the underlying thrombo c
occlusion. Stabilizing the clot with aspirin takes precedence over trea ng the
bradycardia, which is o en a secondary reflex to the inferior/posterior wall MI.
,Ques on 3: Stroke Priori za on
Clinical Scenario: A 65-year-old pa ent is admi ed with a suspected acute ischemic
stroke. The pa ent's last known well me was 2.5 hours ago. The pa ent has a history of
hypertension and takes warfarin for atrial fibrilla on. The pa ent's current INR is 3.2.
Ques on Stem: Which ac on should the nurse priori ze?
Op ons:
A. Administer IV recombinant ssue plasminogen ac vator (tPA) as prescribed
immediately.
B. No fy the healthcare provider that the pa ent is not a candidate for tPA.
C. Prepare the pa ent for an emergent CT scan of the head.
D. Administer Vitamin K 10 mg IV push to reverse the warfarin.
Answer and Ra onale
Correct Answer: B. No fy the healthcare provider that the pa ent is not a candidate for
tPA.
Cogni ve Level: Evalua ng
Client Needs Category: Reduc on of Risk Poten al
Main Lesson / Takeaway: An elevated INR (>1.7) in a pa ent on warfarin is an absolute
contraindica on for tPA due to an unacceptably high risk of fatal intracranial
hemorrhage.
Detailed Ra onale: While me is brain and tPA is the gold standard for ischemic stroke,
the nurse must recognize absolute contraindica ons. An INR of 3.2 indicates significant
an coagula on, making the pa ent a high risk for hemorrhagic conversion.
Administering tPA would be dangerous and poten ally fatal. Op on A is incorrect
because administering tPA would violate the strict exclusion criteria. Op on C (CT scan)
is a standard part of the workup to rule out hemorrhage, but the nurse must first
recognize the cri cal lab value and stop the tPA administra on process. The provider
needs to be no fied immediately to alter the treatment plan. Op on D (Vitamin K) is not
emergent; reversing the INR would take me, and the risk of tPA is immediate. The
correct ac on is to recognize the contraindica on and communicate it to the provider to
prevent harm.
Ques on 4: Gastrointes nal Bleeding
, Clinical Scenario: A 58-year-old pa ent with a history of alcohol abuse is admi ed with
dark, tarry stools and complaints of dizziness. The pa ent vomits 250 mL of bright red
blood. Vital signs are: HR 122 bpm, BP 88/52 mmHg, RR 22 bpm. Lab results show Hgb
7.2 g/dL and Hct 21%.
Ques on Stem: What is the priority nursing interven on?
Op ons:
A. Ini ate two large-bore IV lines and administer normal saline.
B. Prepare to administer a blood transfusion of packed red blood cells.
C. Administer IV pantoprazole (Protonix) per protocol.
D. Insert a nasogastric (NG) tube for gastric lavage.
Answer and Ra onale
Correct Answer: A. Ini ate two large-bore IV lines and administer normal saline.
Cogni ve Level: Analyzing
Client Needs Category: Physiological Adapta on
Main Lesson / Takeaway: In a pa ent with ac ve hemorrhaging and hemodynamic
instability, the immediate priority is to restore intravascular volume with isotonic
crystalloids to prevent hypovolemic shock.
Detailed Ra onale: The pa ent is showing signs of hypovolemic shock (tachycardia,
hypotension, low Hgb/Hct) from an upper GI bleed. The ABCs and the immediate need
for volume resuscita on take priority. The first interven on is to secure IV access and
rapidly infuse normal saline or lactated Ringer's to maintain perfusion to vital
organs. Op on B (blood transfusion) is a cri cal interven on but cannot be ini ated
before the blood is typed/crossmatched, which takes me. Crystalloids are the
immediate first-line for volume expansion. Op on C (pantoprazole) is a treatment to
reduce acid and promote clo ng, but it does not address the immediate life-threatening
hypotension and volume loss. Op on D (NG tube) is a diagnos c and therapeu c
interven on, but it is not the immediate priority in a pa ent who is ac vely
hemodynamically unstable; securing the airway and circula on come first.
Ques on 5: Post-Opera ve Care
Clinical Scenario: A 74-year-old pa ent is 4 hours post-opera ve from a total knee
replacement. The pa ent is receiving IV morphine via a pa ent-controlled analgesia
NCLEX-Style Applica on & Analysis Ques ons
Ques on 1: Acute Respiratory Distress
Clinical Scenario: A 68-year-old pa ent with a history of chronic obstruc ve pulmonary
disease (COPD) is admi ed with pneumonia. The pa ent is restless, anxious, and reports
increasing shortness of breath. Vital signs: HR 118 bpm, RR 36 bpm, BP 148/88 mmHg,
SpO2 88% on 2 L/min nasal cannula. Ausculta on reveals coarse crackles in the right
lower lobe and diminished breath sounds throughout.
Ques on Stem: Which ac on should the nurse take first?
Op ons:
A. Administer the prescribed PRN albuterol nebulizer treatment.
B. Reposi on the pa ent to a high-Fowler's posi on.
C. Prepare for immediate endotracheal intuba on.
D. Increase the oxygen flow rate to 4 L/min via nasal cannula.
Answer and Ra onale
Correct Answer: B. Reposi on the pa ent to a high-Fowler's posi on.
Cogni ve Level: Applying
Client Needs Category: Physiological Adapta on
Main Lesson / Takeaway: The first ac on for a pa ent in respiratory distress is always to
posi on the airway for op mal ven la on.
Detailed Ra onale: The priority in any respiratory emergency is to ensure a patent
airway and maximize ven la on. High-Fowler's posi on uses gravity to lower the
diaphragm, allowing for greater lung expansion and improved gas exchange. This is a
rapid, non-invasive interven on that directly addresses the pa ent's hypoxia and
dyspnea. Op on A (albuterol) would be appropriate for bronchospasm, but it is a
treatment that takes me to administer and is not the immediate first step; posi oning
must occur first. Op on C (intuba on) is a poten al interven on if the pa ent fails to
respond to less invasive measures, but it is not the first ac on and carries significant
risks. Op on D (increasing oxygen) might be needed, but for a COPD pa ent, high-flow
oxygen can suppress the hypoxic drive, and reposi oning is a safer and more immediate
, ac on to improve mechanics before adjus ng oxygen. The immediate priority is to
op mize the pa ent's own physiological ability to breathe effec vely.
Ques on 2: Myocardial Infarc on Pharmacology
Clinical Scenario: A 72-year-old pa ent is brought to the emergency department with
crushing substernal chest pain radia ng to the jaw, nausea, and diaphoresis. An ECG
shows ST-segment eleva on in leads V1–V4. The pa ent's blood pressure is 90/62
mmHg, and heart rate is 48 bpm.
Ques on Stem: The nurse an cipates administering which medica on first?
Op ons:
A. Nitroglycerin 0.4 mg sublingual
B. Morphine sulfate 2 mg IV push
C. Atropine 0.5 mg IV push
D. Aspirin 324 mg chewable
Answer and Ra onale
Correct Answer: D. Aspirin 324 mg chewable
Cogni ve Level: Analyzing
Client Needs Category: Pharmacological and Parenteral Therapies
Main Lesson / Takeaway: In an acute STEMI, aspirin is the most cri cal and immediate
interven on to reduce mortality by preven ng further platelet aggrega on.
Detailed Ra onale: Aspirin is a cornerstone of acute MI management because it quickly
inhibits platelet aggrega on, preven ng the expansion of the exis ng thrombus. It is the
single most important medica on to administer immediately upon suspicion of an
MI. Op on A (Nitroglycerin) is a vasodilator that can be given for chest pain, but it is
rela vely contraindicated with a systolic BP <90 mmHg, as it could cause further
dangerous hypotension. Op on B (Morphine) is used for pain and to reduce preload, but
it is not the first priority over aspirin and can also cause vasodila on, worsening
hypotension in this pa ent. Op on C (Atropine) is used for symptoma c bradycardia,
but the primary and immediate therapy is aspirin to address the underlying thrombo c
occlusion. Stabilizing the clot with aspirin takes precedence over trea ng the
bradycardia, which is o en a secondary reflex to the inferior/posterior wall MI.
,Ques on 3: Stroke Priori za on
Clinical Scenario: A 65-year-old pa ent is admi ed with a suspected acute ischemic
stroke. The pa ent's last known well me was 2.5 hours ago. The pa ent has a history of
hypertension and takes warfarin for atrial fibrilla on. The pa ent's current INR is 3.2.
Ques on Stem: Which ac on should the nurse priori ze?
Op ons:
A. Administer IV recombinant ssue plasminogen ac vator (tPA) as prescribed
immediately.
B. No fy the healthcare provider that the pa ent is not a candidate for tPA.
C. Prepare the pa ent for an emergent CT scan of the head.
D. Administer Vitamin K 10 mg IV push to reverse the warfarin.
Answer and Ra onale
Correct Answer: B. No fy the healthcare provider that the pa ent is not a candidate for
tPA.
Cogni ve Level: Evalua ng
Client Needs Category: Reduc on of Risk Poten al
Main Lesson / Takeaway: An elevated INR (>1.7) in a pa ent on warfarin is an absolute
contraindica on for tPA due to an unacceptably high risk of fatal intracranial
hemorrhage.
Detailed Ra onale: While me is brain and tPA is the gold standard for ischemic stroke,
the nurse must recognize absolute contraindica ons. An INR of 3.2 indicates significant
an coagula on, making the pa ent a high risk for hemorrhagic conversion.
Administering tPA would be dangerous and poten ally fatal. Op on A is incorrect
because administering tPA would violate the strict exclusion criteria. Op on C (CT scan)
is a standard part of the workup to rule out hemorrhage, but the nurse must first
recognize the cri cal lab value and stop the tPA administra on process. The provider
needs to be no fied immediately to alter the treatment plan. Op on D (Vitamin K) is not
emergent; reversing the INR would take me, and the risk of tPA is immediate. The
correct ac on is to recognize the contraindica on and communicate it to the provider to
prevent harm.
Ques on 4: Gastrointes nal Bleeding
, Clinical Scenario: A 58-year-old pa ent with a history of alcohol abuse is admi ed with
dark, tarry stools and complaints of dizziness. The pa ent vomits 250 mL of bright red
blood. Vital signs are: HR 122 bpm, BP 88/52 mmHg, RR 22 bpm. Lab results show Hgb
7.2 g/dL and Hct 21%.
Ques on Stem: What is the priority nursing interven on?
Op ons:
A. Ini ate two large-bore IV lines and administer normal saline.
B. Prepare to administer a blood transfusion of packed red blood cells.
C. Administer IV pantoprazole (Protonix) per protocol.
D. Insert a nasogastric (NG) tube for gastric lavage.
Answer and Ra onale
Correct Answer: A. Ini ate two large-bore IV lines and administer normal saline.
Cogni ve Level: Analyzing
Client Needs Category: Physiological Adapta on
Main Lesson / Takeaway: In a pa ent with ac ve hemorrhaging and hemodynamic
instability, the immediate priority is to restore intravascular volume with isotonic
crystalloids to prevent hypovolemic shock.
Detailed Ra onale: The pa ent is showing signs of hypovolemic shock (tachycardia,
hypotension, low Hgb/Hct) from an upper GI bleed. The ABCs and the immediate need
for volume resuscita on take priority. The first interven on is to secure IV access and
rapidly infuse normal saline or lactated Ringer's to maintain perfusion to vital
organs. Op on B (blood transfusion) is a cri cal interven on but cannot be ini ated
before the blood is typed/crossmatched, which takes me. Crystalloids are the
immediate first-line for volume expansion. Op on C (pantoprazole) is a treatment to
reduce acid and promote clo ng, but it does not address the immediate life-threatening
hypotension and volume loss. Op on D (NG tube) is a diagnos c and therapeu c
interven on, but it is not the immediate priority in a pa ent who is ac vely
hemodynamically unstable; securing the airway and circula on come first.
Ques on 5: Post-Opera ve Care
Clinical Scenario: A 74-year-old pa ent is 4 hours post-opera ve from a total knee
replacement. The pa ent is receiving IV morphine via a pa ent-controlled analgesia
