2026 Medical Surgical Nursing Priority Care
Practice Questions Answer Rationales
Emergency Assessment ABCs Shock Sepsis
Deterioration Clinical Decisions
1. A nurse is caring for a patient who was admitted with a diagnosis of sepsis.
Which of the following assessment findings is the priority for the nurse to
address?
A. A temperature of 101.2°F
B. A blood pressure of 82/48 mmHg
C. A heart rate of 110 beats per minute
D. A respiratory rate of 24 breaths per minute
Answer: B. A blood pressure of 82/48 mmHg
Rationale: The priority in sepsis management is to maintain adequate tissue
perfusion. A blood pressure of 82/48 mmHg indicates hypotension and inadequate
perfusion, which can lead to organ failure and death. While fever, tachycardia, and
tachypnea are signs of sepsis, hypotension is the most life-threatening finding and
requires immediate intervention, such as fluid resuscitation and vasopressors.
2. A patient is admitted with an acute gastrointestinal bleed. Which of the
following nursing interventions is the priority?
A. Administer a prescribed proton pump inhibitor.
B. Insert two large-bore IV catheters.
C. Type and crossmatch for blood products.
D. Monitor hemoglobin and hematocrit levels.
Answer: B. Insert two large-bore IV catheters.
Rationale: The priority in a patient with an acute GI bleed is to establish vascular
access for fluid resuscitation and potential blood transfusion. Inserting two large-
bore IV catheters is the immediate priority to prepare for volume replacement.
While medications and blood products are important, they cannot be administered
without adequate IV access.
3. A nurse is assessing a patient who is one day postoperative from abdominal
surgery. The patient's heart rate has increased from 88 to 118 beats per
minute, and blood pressure has dropped from 120/76 to 98/60 mmHg. Which
,of the following actions should the nurse take first?
A. Administer the prescribed analgesic.
B. Assess the surgical incision and abdominal dressing.
C. Increase the IV fluid rate as ordered.
D. Notify the provider.
Answer: B. Assess the surgical incision and abdominal dressing.
Rationale: The patient is exhibiting signs of hypovolemic shock, likely due to
postoperative bleeding. The first action is to assess for the source of the bleeding
by inspecting the surgical incision and dressing. This assessment will provide
critical information to guide the next interventions, such as notifying the provider
and increasing IV fluids.
4. A patient is admitted with a diagnosis of anaphylactic shock. Which of the
following medications is the priority to administer?
A. Diphenhydramine
B. Epinephrine
C. Methylprednisolone
D. Albuterol
Answer: B. Epinephrine
Rationale: Epinephrine is the first-line treatment for anaphylactic shock. It works
rapidly to reverse bronchospasm and vasodilation by stimulating alpha and beta-
adrenergic receptors. It should be administered immediately via intramuscular
injection. Antihistamines and corticosteroids are secondary treatments.
5. A nurse is caring for a patient with a diagnosis of septic shock. Which of the
following laboratory values indicates the patient is developing disseminated
intravascular coagulation (DIC)?
A. Elevated platelet count
B. Prolonged PT and aPTT
C. Elevated fibrinogen level
D. Decreased D-dimer level
Answer: B. Prolonged PT and aPTT
Rationale: DIC is a complication of septic shock characterized by widespread
activation of the coagulation cascade. This leads to the consumption of clotting
factors and platelets, resulting in prolonged PT and aPTT, decreased platelet count,
decreased fibrinogen, and elevated D-dimer levels.
,6. A patient is admitted with a diagnosis of a ruptured abdominal aortic
aneurysm. Which of the following clinical manifestations is the priority for the
nurse to recognize?
A. Severe back pain
B. A pulsating abdominal mass
C. Hypotension and tachycardia
D. Nausea and vomiting
Answer: C. Hypotension and tachycardia
Rationale: A ruptured abdominal aortic aneurysm is a life-threatening emergency.
Hypotension and tachycardia indicate massive internal bleeding and hypovolemic
shock. While back pain and a pulsating mass are classic signs, the priority is to
recognize the signs of shock and intervene immediately.
7. A nurse is assessing a patient who was admitted with a diagnosis of acute
respiratory distress syndrome (ARDS). Which of the following findings is
most concerning?
A. A respiratory rate of 28 breaths per minute
B. Oxygen saturation of 88% on a non-rebreather mask
C. Bilateral crackles in the lungs
D. A PaO2 of 60 mmHg
Answer: B. Oxygen saturation of 88% on a non-rebreather mask
Rationale: ARDS is characterized by severe hypoxemia that is refractory to
oxygen therapy. An oxygen saturation of 88% despite receiving high-flow oxygen
via a non-rebreather mask indicates severe impairment of gas exchange and
impending respiratory failure. This requires immediate intervention, including
preparation for mechanical ventilation.
8. A patient is admitted with a diagnosis of a stroke. Which of the following
findings is the priority for the nurse to report to the provider?
A. A blood pressure of 180/100 mmHg
B. A sudden decrease in the level of consciousness
C. A headache rated 6 out of 10
D. Nausea and vomiting
Answer: B. A sudden decrease in the level of consciousness
Rationale: A sudden decrease in the level of consciousness in a patient with a
stroke indicates neurological deterioration, possibly due to increased intracranial
pressure or expansion of the stroke. This is a critical finding that requires
immediate notification of the provider and possible intervention.
, 9. A nurse is caring for a patient with a diagnosis of a pulmonary embolism.
Which of the following nursing interventions is the priority?
A. Administer the prescribed anticoagulant.
B. Apply supplemental oxygen.
C. Place the patient in a high-Fowler's position.
D. Obtain a D-dimer level.
Answer: B. Apply supplemental oxygen.
Rationale: The priority in a pulmonary embolism is to ensure adequate
oxygenation. Applying supplemental oxygen is the immediate intervention. While
administering anticoagulants is critical, oxygenation is the first priority.
10. A patient is admitted with a diagnosis of diabetic ketoacidosis (DKA).
Which of the following laboratory values is the priority for the nurse to
monitor?
A. Serum glucose
B. Serum potassium
C. Serum sodium
D. Serum bicarbonate
Answer: B. Serum potassium
Rationale: The most life-threatening complication of DKA is hyperkalemia or
hypokalemia, both of which can lead to fatal cardiac arrhythmias. While
monitoring glucose and bicarbonate is important, monitoring potassium levels is
the priority due to the risk of cardiac arrest.
11. A nurse is assessing a patient who is one day postoperative from a hip
replacement. The patient suddenly develops shortness of breath, pleuritic
chest pain, and tachycardia. Which of the following actions should the nurse
take first?
A. Administer the prescribed analgesic.
B. Apply supplemental oxygen.
C. Notify the provider.
D. Obtain a chest X-ray.
Answer: B. Apply supplemental oxygen.
Rationale: The patient is exhibiting signs of a pulmonary embolism. The priority
is to ensure adequate oxygenation by applying supplemental oxygen. While
notifying the provider is important, applying oxygen is the immediate intervention
to prevent further deterioration.
Practice Questions Answer Rationales
Emergency Assessment ABCs Shock Sepsis
Deterioration Clinical Decisions
1. A nurse is caring for a patient who was admitted with a diagnosis of sepsis.
Which of the following assessment findings is the priority for the nurse to
address?
A. A temperature of 101.2°F
B. A blood pressure of 82/48 mmHg
C. A heart rate of 110 beats per minute
D. A respiratory rate of 24 breaths per minute
Answer: B. A blood pressure of 82/48 mmHg
Rationale: The priority in sepsis management is to maintain adequate tissue
perfusion. A blood pressure of 82/48 mmHg indicates hypotension and inadequate
perfusion, which can lead to organ failure and death. While fever, tachycardia, and
tachypnea are signs of sepsis, hypotension is the most life-threatening finding and
requires immediate intervention, such as fluid resuscitation and vasopressors.
2. A patient is admitted with an acute gastrointestinal bleed. Which of the
following nursing interventions is the priority?
A. Administer a prescribed proton pump inhibitor.
B. Insert two large-bore IV catheters.
C. Type and crossmatch for blood products.
D. Monitor hemoglobin and hematocrit levels.
Answer: B. Insert two large-bore IV catheters.
Rationale: The priority in a patient with an acute GI bleed is to establish vascular
access for fluid resuscitation and potential blood transfusion. Inserting two large-
bore IV catheters is the immediate priority to prepare for volume replacement.
While medications and blood products are important, they cannot be administered
without adequate IV access.
3. A nurse is assessing a patient who is one day postoperative from abdominal
surgery. The patient's heart rate has increased from 88 to 118 beats per
minute, and blood pressure has dropped from 120/76 to 98/60 mmHg. Which
,of the following actions should the nurse take first?
A. Administer the prescribed analgesic.
B. Assess the surgical incision and abdominal dressing.
C. Increase the IV fluid rate as ordered.
D. Notify the provider.
Answer: B. Assess the surgical incision and abdominal dressing.
Rationale: The patient is exhibiting signs of hypovolemic shock, likely due to
postoperative bleeding. The first action is to assess for the source of the bleeding
by inspecting the surgical incision and dressing. This assessment will provide
critical information to guide the next interventions, such as notifying the provider
and increasing IV fluids.
4. A patient is admitted with a diagnosis of anaphylactic shock. Which of the
following medications is the priority to administer?
A. Diphenhydramine
B. Epinephrine
C. Methylprednisolone
D. Albuterol
Answer: B. Epinephrine
Rationale: Epinephrine is the first-line treatment for anaphylactic shock. It works
rapidly to reverse bronchospasm and vasodilation by stimulating alpha and beta-
adrenergic receptors. It should be administered immediately via intramuscular
injection. Antihistamines and corticosteroids are secondary treatments.
5. A nurse is caring for a patient with a diagnosis of septic shock. Which of the
following laboratory values indicates the patient is developing disseminated
intravascular coagulation (DIC)?
A. Elevated platelet count
B. Prolonged PT and aPTT
C. Elevated fibrinogen level
D. Decreased D-dimer level
Answer: B. Prolonged PT and aPTT
Rationale: DIC is a complication of septic shock characterized by widespread
activation of the coagulation cascade. This leads to the consumption of clotting
factors and platelets, resulting in prolonged PT and aPTT, decreased platelet count,
decreased fibrinogen, and elevated D-dimer levels.
,6. A patient is admitted with a diagnosis of a ruptured abdominal aortic
aneurysm. Which of the following clinical manifestations is the priority for the
nurse to recognize?
A. Severe back pain
B. A pulsating abdominal mass
C. Hypotension and tachycardia
D. Nausea and vomiting
Answer: C. Hypotension and tachycardia
Rationale: A ruptured abdominal aortic aneurysm is a life-threatening emergency.
Hypotension and tachycardia indicate massive internal bleeding and hypovolemic
shock. While back pain and a pulsating mass are classic signs, the priority is to
recognize the signs of shock and intervene immediately.
7. A nurse is assessing a patient who was admitted with a diagnosis of acute
respiratory distress syndrome (ARDS). Which of the following findings is
most concerning?
A. A respiratory rate of 28 breaths per minute
B. Oxygen saturation of 88% on a non-rebreather mask
C. Bilateral crackles in the lungs
D. A PaO2 of 60 mmHg
Answer: B. Oxygen saturation of 88% on a non-rebreather mask
Rationale: ARDS is characterized by severe hypoxemia that is refractory to
oxygen therapy. An oxygen saturation of 88% despite receiving high-flow oxygen
via a non-rebreather mask indicates severe impairment of gas exchange and
impending respiratory failure. This requires immediate intervention, including
preparation for mechanical ventilation.
8. A patient is admitted with a diagnosis of a stroke. Which of the following
findings is the priority for the nurse to report to the provider?
A. A blood pressure of 180/100 mmHg
B. A sudden decrease in the level of consciousness
C. A headache rated 6 out of 10
D. Nausea and vomiting
Answer: B. A sudden decrease in the level of consciousness
Rationale: A sudden decrease in the level of consciousness in a patient with a
stroke indicates neurological deterioration, possibly due to increased intracranial
pressure or expansion of the stroke. This is a critical finding that requires
immediate notification of the provider and possible intervention.
, 9. A nurse is caring for a patient with a diagnosis of a pulmonary embolism.
Which of the following nursing interventions is the priority?
A. Administer the prescribed anticoagulant.
B. Apply supplemental oxygen.
C. Place the patient in a high-Fowler's position.
D. Obtain a D-dimer level.
Answer: B. Apply supplemental oxygen.
Rationale: The priority in a pulmonary embolism is to ensure adequate
oxygenation. Applying supplemental oxygen is the immediate intervention. While
administering anticoagulants is critical, oxygenation is the first priority.
10. A patient is admitted with a diagnosis of diabetic ketoacidosis (DKA).
Which of the following laboratory values is the priority for the nurse to
monitor?
A. Serum glucose
B. Serum potassium
C. Serum sodium
D. Serum bicarbonate
Answer: B. Serum potassium
Rationale: The most life-threatening complication of DKA is hyperkalemia or
hypokalemia, both of which can lead to fatal cardiac arrhythmias. While
monitoring glucose and bicarbonate is important, monitoring potassium levels is
the priority due to the risk of cardiac arrest.
11. A nurse is assessing a patient who is one day postoperative from a hip
replacement. The patient suddenly develops shortness of breath, pleuritic
chest pain, and tachycardia. Which of the following actions should the nurse
take first?
A. Administer the prescribed analgesic.
B. Apply supplemental oxygen.
C. Notify the provider.
D. Obtain a chest X-ray.
Answer: B. Apply supplemental oxygen.
Rationale: The patient is exhibiting signs of a pulmonary embolism. The priority
is to ensure adequate oxygenation by applying supplemental oxygen. While
notifying the provider is important, applying oxygen is the immediate intervention
to prevent further deterioration.
