MSN-BRUNNER: Brunner & Suddarth’s Medical-Surgical
Nursing Exam Prep with Detailed Rationales
Course Code: NCLEX_RN
Course Name: Brunner & Suddarth’s Medical-Surgical Nursing –
Comprehensive Test-Prep Notes & Exam Rationales
Topic: Advanced Medical-Surgical Systemic Management,
Pathophysiology, and Care
Academic Year: 2026/2027
1. A nurse is caring for a patient in the intensive care unit who was admitted
with severe diabetic ketoacidosis (DKA). The patient's initial laboratory
results revealed a blood glucose level of 550 mg/dL and a serum potassium
level of 3.2 mEq/L. An intravenous infusion of regular insulin has been
ordered. Which action must the nurse take first before initiating the insulin
infusion?
A. Administer a rapid intravenous bolus of regular insulin at 0.1 units/kg.
B. Administer intravenous potassium replacement therapy to raise the
serum potassium above 3.3 mEq/L.
, C. Insert an indwelling urinary catheter to monitor strict hourly urine output
metrics.
D. Draw a baseline arterial blood gas to determine the precise anion gap
value.
CORRECT ANSWER: B
RATIONALE: In the management of diabetic ketoacidosis (DKA), if a
patient's serum potassium level is below 3.3 mEq/L, insulin therapy must be
held and potassium replacement initiated first. Administering insulin drives
potassium shifts into the intracellular space, which can cause severe, life-
threatening hypokalemia, cardiac arrhythmias, or respiratory arrest.
Distractor A is contraindicated when hypokalemia is present. Distractors C
and D are appropriate management components but do not take clinical
priority over correcting life-threatening hypokalemia.
2. A patient with a history of liver cirrhosis is admitted to the medical-surgical
unit with severe ascites and structural fluid shifts. The healthcare provider
schedules a therapeutic paracentesis. Which nursing intervention is crucial
immediately following the removal of 5 to 6 liters of ascitic fluid to prevent
circulatory collapse?
A. Place the patient in a prone position for at least 4 hours.
B. Administer prescribed intravenous albumin infusions.
C. Restrict all intravenous crystalloid infusions for the next 24 hours.
D. Infuse an immediate dose of high-dose loop diuretics.
CORRECT ANSWER: B
RATIONALE: Removing large volumes of ascitic fluid (greater than 5
liters) during a paracentesis alters intra-abdominal pressure, causing
vasodilation and fluid shifts out of the vascular space. This can lead to post-
paracentesis circulatory dysfunction (PCD). Administering intravenous
albumin acts as an oncotic agent to maintain intravascular volume and
prevent severe hypovolemia, hypotension, and renal failure. Distractor A is
inappropriate and uncomfortable; distractors C and D worsen intravascular
volume depletion.
3. A nurse is reviewing the arterial blood gas (ABG) results of a patient
admitted with an acute exacerbation of Chronic Obstructive Pulmonary
Disease (COPD). The results are as follows: pH 7.31, PaCO₂ 58 mmHg,
, HCO₃⁻ 26 mEq/L, and PaO₂ 55 mmHg. How should the nurse accurately
interpret this patient's acid-base imbalance?
A. Uncompensated metabolic acidosis with mild hypoxia.
B. Uncompensated respiratory acidosis with severe hypoxemia.
C. Fully compensated respiratory alkalosis with hypercapnia.
D. Partially compensated metabolic alkalosis with hypoxemia.
CORRECT ANSWER: B
RATIONALE: The pH is 7.31 (below the normal reference range of
7.35–7.45), indicating an acidotic state. The PaCO₂ is elevated at 58 mmHg
(normal is 35–45 mmHg), which accounts for the acidosis, pointing to a
respiratory origin. The HCO₃⁻ is normal at 26 mEq/L (normal is 22–26
mEq/L), indicating that renal compensation has not yet occurred (making it
uncompensated). The PaO₂ is 55 mmHg, demonstrating severe hypoxemia.
Therefore, this represents an uncompensated respiratory acidosis with
severe hypoxemia. Distractors A, C, and D are incorrect interpretations of
these values.
4. A patient is admitted to the surgical ward following a total thyroidectomy
for the treatment of thyroid cancer. During the post-operative assessment,
the nurse notes that the patient exhibits hyperreflexia, muscle twitching, and
positive Chvostek’s and Trousseau’s signs. Which electrolyte imbalance
does the nurse suspect?
A. Severe hyperkalemia
B. Hypercalcemia
C. Hypocalcemia
D. Hyponatremia
CORRECT ANSWER: C
RATIONALE: During a total thyroidectomy, the parathyroid glands can
be accidentally damaged or removed, resulting in a sudden drop in
parathyroid hormone (PTH) and subsequent hypocalcemia. Hypocalcemia
causes neuromuscular irritability, which presents clinically as muscle
spasms, hyperreflexia, a positive Chvostek's sign (facial twitching when the
facial nerve is tapped), and a positive Trousseau's sign (carpopedal spasm
induced by inflating a blood pressure cuff). Distractors A, B, and D do not
produce these specific neuromuscular findings.
, 5. A patient with a history of deep vein thrombosis (DVT) is admitted with
sudden onset chest pain, severe dyspnea, tachypnea, and a localized drop in
oxygen saturation. The provider suspects an acute pulmonary embolism
(PE). Which diagnostic study is considered the gold standard to rapidly
confirm the presence and location of a PE?
A. Standard baseline 12-lead Electrocardiogram (ECG).
B. Transthoracic Echocardiogram (TTE).
C. Computed Tomography Pulmonary Angiography (CTPA).
D. High-resolution chest X-ray.
CORRECT ANSWER: C
RATIONALE: Computed Tomography Pulmonary Angiography
(CTPA) is the first-line, gold-standard imaging modality used to definitively
diagnose an acute pulmonary embolism. It provides visualization of the
pulmonary vasculature, allowing direct localization of the thrombus.
Distractor A may show non-specific changes (such as an S1Q3T3 pattern)
but is not diagnostic. Distractor B evaluates right ventricular strain but does
not confirm a clot. Distractor D rule out other causes of dyspnea but cannot
visualize a pulmonary embolism.
6. A patient is admitted to the neurological floor with a confirmed acute
ischemic stroke. The stroke team is evaluating the patient for the
administration of intravenous tissue plasminogen activator (tPA). Which
criteria would absolutely contraindicate the use of tPA in this patient?
A. Age older than 65 years at the onset of symptoms.
B. Current history of intracranial hemorrhage or major surgery within
the past 14 days.
C. Blood pressure reading stabilized at 170/95 mmHg.
D. Baseline blood glucose reading of 140 mg/dL.
CORRECT ANSWER: B
RATIONALE: Intravenous tPA is a potent thrombolytic agent. Absolute
contraindications include evidence of intracranial hemorrhage, active
internal bleeding, a history of major surgery or significant trauma within the
past 14 days, or a plate count below 100,000/mm³. Administering tPA in
these scenarios carries a high risk of catastrophic, fatal bleeding. Distractor
A is not a contraindication; distractor C is within safe guidelines (BP must
Nursing Exam Prep with Detailed Rationales
Course Code: NCLEX_RN
Course Name: Brunner & Suddarth’s Medical-Surgical Nursing –
Comprehensive Test-Prep Notes & Exam Rationales
Topic: Advanced Medical-Surgical Systemic Management,
Pathophysiology, and Care
Academic Year: 2026/2027
1. A nurse is caring for a patient in the intensive care unit who was admitted
with severe diabetic ketoacidosis (DKA). The patient's initial laboratory
results revealed a blood glucose level of 550 mg/dL and a serum potassium
level of 3.2 mEq/L. An intravenous infusion of regular insulin has been
ordered. Which action must the nurse take first before initiating the insulin
infusion?
A. Administer a rapid intravenous bolus of regular insulin at 0.1 units/kg.
B. Administer intravenous potassium replacement therapy to raise the
serum potassium above 3.3 mEq/L.
, C. Insert an indwelling urinary catheter to monitor strict hourly urine output
metrics.
D. Draw a baseline arterial blood gas to determine the precise anion gap
value.
CORRECT ANSWER: B
RATIONALE: In the management of diabetic ketoacidosis (DKA), if a
patient's serum potassium level is below 3.3 mEq/L, insulin therapy must be
held and potassium replacement initiated first. Administering insulin drives
potassium shifts into the intracellular space, which can cause severe, life-
threatening hypokalemia, cardiac arrhythmias, or respiratory arrest.
Distractor A is contraindicated when hypokalemia is present. Distractors C
and D are appropriate management components but do not take clinical
priority over correcting life-threatening hypokalemia.
2. A patient with a history of liver cirrhosis is admitted to the medical-surgical
unit with severe ascites and structural fluid shifts. The healthcare provider
schedules a therapeutic paracentesis. Which nursing intervention is crucial
immediately following the removal of 5 to 6 liters of ascitic fluid to prevent
circulatory collapse?
A. Place the patient in a prone position for at least 4 hours.
B. Administer prescribed intravenous albumin infusions.
C. Restrict all intravenous crystalloid infusions for the next 24 hours.
D. Infuse an immediate dose of high-dose loop diuretics.
CORRECT ANSWER: B
RATIONALE: Removing large volumes of ascitic fluid (greater than 5
liters) during a paracentesis alters intra-abdominal pressure, causing
vasodilation and fluid shifts out of the vascular space. This can lead to post-
paracentesis circulatory dysfunction (PCD). Administering intravenous
albumin acts as an oncotic agent to maintain intravascular volume and
prevent severe hypovolemia, hypotension, and renal failure. Distractor A is
inappropriate and uncomfortable; distractors C and D worsen intravascular
volume depletion.
3. A nurse is reviewing the arterial blood gas (ABG) results of a patient
admitted with an acute exacerbation of Chronic Obstructive Pulmonary
Disease (COPD). The results are as follows: pH 7.31, PaCO₂ 58 mmHg,
, HCO₃⁻ 26 mEq/L, and PaO₂ 55 mmHg. How should the nurse accurately
interpret this patient's acid-base imbalance?
A. Uncompensated metabolic acidosis with mild hypoxia.
B. Uncompensated respiratory acidosis with severe hypoxemia.
C. Fully compensated respiratory alkalosis with hypercapnia.
D. Partially compensated metabolic alkalosis with hypoxemia.
CORRECT ANSWER: B
RATIONALE: The pH is 7.31 (below the normal reference range of
7.35–7.45), indicating an acidotic state. The PaCO₂ is elevated at 58 mmHg
(normal is 35–45 mmHg), which accounts for the acidosis, pointing to a
respiratory origin. The HCO₃⁻ is normal at 26 mEq/L (normal is 22–26
mEq/L), indicating that renal compensation has not yet occurred (making it
uncompensated). The PaO₂ is 55 mmHg, demonstrating severe hypoxemia.
Therefore, this represents an uncompensated respiratory acidosis with
severe hypoxemia. Distractors A, C, and D are incorrect interpretations of
these values.
4. A patient is admitted to the surgical ward following a total thyroidectomy
for the treatment of thyroid cancer. During the post-operative assessment,
the nurse notes that the patient exhibits hyperreflexia, muscle twitching, and
positive Chvostek’s and Trousseau’s signs. Which electrolyte imbalance
does the nurse suspect?
A. Severe hyperkalemia
B. Hypercalcemia
C. Hypocalcemia
D. Hyponatremia
CORRECT ANSWER: C
RATIONALE: During a total thyroidectomy, the parathyroid glands can
be accidentally damaged or removed, resulting in a sudden drop in
parathyroid hormone (PTH) and subsequent hypocalcemia. Hypocalcemia
causes neuromuscular irritability, which presents clinically as muscle
spasms, hyperreflexia, a positive Chvostek's sign (facial twitching when the
facial nerve is tapped), and a positive Trousseau's sign (carpopedal spasm
induced by inflating a blood pressure cuff). Distractors A, B, and D do not
produce these specific neuromuscular findings.
, 5. A patient with a history of deep vein thrombosis (DVT) is admitted with
sudden onset chest pain, severe dyspnea, tachypnea, and a localized drop in
oxygen saturation. The provider suspects an acute pulmonary embolism
(PE). Which diagnostic study is considered the gold standard to rapidly
confirm the presence and location of a PE?
A. Standard baseline 12-lead Electrocardiogram (ECG).
B. Transthoracic Echocardiogram (TTE).
C. Computed Tomography Pulmonary Angiography (CTPA).
D. High-resolution chest X-ray.
CORRECT ANSWER: C
RATIONALE: Computed Tomography Pulmonary Angiography
(CTPA) is the first-line, gold-standard imaging modality used to definitively
diagnose an acute pulmonary embolism. It provides visualization of the
pulmonary vasculature, allowing direct localization of the thrombus.
Distractor A may show non-specific changes (such as an S1Q3T3 pattern)
but is not diagnostic. Distractor B evaluates right ventricular strain but does
not confirm a clot. Distractor D rule out other causes of dyspnea but cannot
visualize a pulmonary embolism.
6. A patient is admitted to the neurological floor with a confirmed acute
ischemic stroke. The stroke team is evaluating the patient for the
administration of intravenous tissue plasminogen activator (tPA). Which
criteria would absolutely contraindicate the use of tPA in this patient?
A. Age older than 65 years at the onset of symptoms.
B. Current history of intracranial hemorrhage or major surgery within
the past 14 days.
C. Blood pressure reading stabilized at 170/95 mmHg.
D. Baseline blood glucose reading of 140 mg/dL.
CORRECT ANSWER: B
RATIONALE: Intravenous tPA is a potent thrombolytic agent. Absolute
contraindications include evidence of intracranial hemorrhage, active
internal bleeding, a history of major surgery or significant trauma within the
past 14 days, or a plate count below 100,000/mm³. Administering tPA in
these scenarios carries a high risk of catastrophic, fatal bleeding. Distractor
A is not a contraindication; distractor C is within safe guidelines (BP must
