Saunders Comprehensive Review for the NCLEX-PN®
Examination
9th Edition
20 NCLEX-RN Style MCQs — Medical-Surgical Nursing
1. (Cardiovascular — Acute coronary syndrome)
A 62-year-old man arrives to the ED with substernal chest
pressure that began 45 minutes ago and diaphoresis. Vital signs:
BP 140/86 mmHg, HR 110 bpm, RR 22/min, O₂ sat 95% on room
air. Which nursing action is the highest priority?
A. Give sublingual nitroglycerin and reassess pain within 5
minutes.
B. Obtain a 12-lead ECG immediately and notify the provider.
(Correct)
C. Administer aspirin chewable 325 mg and document time.
D. Start a continuous heparin infusion.
Rationale (correct — B): A 12-lead ECG is the priority diagnostic
step for chest pain because it identifies ST-elevation MI (STEMI)
or other ischemic changes and directs urgent reperfusion
therapy. Early ECG within 10 minutes is foundational to triage
and reperfusion decisions. American Heart Association Journals
Why others are incorrect:
A — Nitroglycerin may relieve ischemic pain but should not
,delay obtaining the ECG. Also contraindicated in suspected right
ventricular infarction or recent phosphodiesterase inhibitor use.
C — Aspirin is indicated emergently and should be given quickly,
but obtaining the ECG is higher priority to determine immediate
reperfusion needs.
D — Heparin may be indicated per protocol but should follow
initial assessment and ECG interpretation and provider orders.
2. (Cardiovascular — Heart failure)
A patient with chronic heart failure is admitted with worsening
dyspnea, bibasilar crackles, and 3+ pitting edema. BNP is
markedly elevated. The nurse administers IV furosemide. Which
assessment finding best indicates the medication is having the
intended effect?
A. Decrease in BNP by 50% within 1 hour.
B. Improved oxygenation and decreased crackles on
auscultation. (Correct)
C. Increase in urinary sodium concentration with no change in
urine output.
D. Rise in heart rate by 20 beats/minute.
Rationale (correct — B): Loop diuretics reduce intravascular
volume and pulmonary congestion; an improvement in
oxygenation and fewer crackles indicate reduced pulmonary
edema and effective diuresis. BNP trends are useful but do not
change dramatically within the first hour.
,Why others are incorrect:
A — BNP decreases more slowly over hours to days; an
immediate 50% drop in 1 hour is unrealistic.
C — Increased urine output is expected; sodium concentration
alone without volume change is less clinically useful.
D — An increased heart rate suggests hemodynamic stress or
side effects, not improvement.
3. (Cardiovascular — Dysrhythmia/priority)
A client with new-onset atrial fibrillation has HR 150 bpm and is
hypotensive with dizziness. What is the nurse’s priority action?
A. Administer oral metoprolol as ordered.
B. Prepare for synchronized cardioversion after sedation.
(Correct)
C. Give digoxin and monitor for therapeutic effect.
D. Obtain electrolyte panel and wait for results before
intervening.
Rationale (correct — B): A hemodynamically unstable patient
(hypotension, dizziness) with a rapid ventricular response needs
immediate synchronized cardioversion to restore perfusion.
Stabilization takes precedence over medication therapy.
Why others are incorrect:
A — Beta-blocker may be indicated in a stable patient; in this
unstable scenario, cardioversion is priority.
C — Digoxin has a slow onset and is not appropriate for
immediate rate control in unstable patients.
, D — While electrolytes are important, waiting for labs in an
unstable patient risks further deterioration.
4. (Respiratory — ABG interpretation)
A patient with COPD exacerbation has an arterial blood gas: pH
7.30, PaCO₂ 60 mmHg, HCO₃⁻ 26 mEq/L. Which interpretation is
correct?
A. Uncompensated metabolic acidosis.
B. Respiratory alkalosis with partial compensation.
C. Acute respiratory acidosis. (Correct)
D. Metabolic alkalosis with respiratory compensation.
Rationale (correct — C): Elevated PaCO₂ (60) with low pH (7.30)
and near-normal HCO₃⁻ indicates an acute respiratory acidosis
(hypoventilation/CO₂ retention) without metabolic
compensation. COPD exacerbations commonly cause acute or
chronic respiratory acidosis.
Why others are incorrect:
A — Metabolic acidosis would show low HCO₃⁻.
B — Respiratory alkalosis would show low PaCO₂ and high pH.
D — Metabolic alkalosis would show elevated HCO₃⁻ and high
pH.
5. (Respiratory — Pulmonary embolism)
A postoperative patient develops sudden pleuritic chest pain,
tachycardia, and oxygen desaturation to 86%. Which immediate
Examination
9th Edition
20 NCLEX-RN Style MCQs — Medical-Surgical Nursing
1. (Cardiovascular — Acute coronary syndrome)
A 62-year-old man arrives to the ED with substernal chest
pressure that began 45 minutes ago and diaphoresis. Vital signs:
BP 140/86 mmHg, HR 110 bpm, RR 22/min, O₂ sat 95% on room
air. Which nursing action is the highest priority?
A. Give sublingual nitroglycerin and reassess pain within 5
minutes.
B. Obtain a 12-lead ECG immediately and notify the provider.
(Correct)
C. Administer aspirin chewable 325 mg and document time.
D. Start a continuous heparin infusion.
Rationale (correct — B): A 12-lead ECG is the priority diagnostic
step for chest pain because it identifies ST-elevation MI (STEMI)
or other ischemic changes and directs urgent reperfusion
therapy. Early ECG within 10 minutes is foundational to triage
and reperfusion decisions. American Heart Association Journals
Why others are incorrect:
A — Nitroglycerin may relieve ischemic pain but should not
,delay obtaining the ECG. Also contraindicated in suspected right
ventricular infarction or recent phosphodiesterase inhibitor use.
C — Aspirin is indicated emergently and should be given quickly,
but obtaining the ECG is higher priority to determine immediate
reperfusion needs.
D — Heparin may be indicated per protocol but should follow
initial assessment and ECG interpretation and provider orders.
2. (Cardiovascular — Heart failure)
A patient with chronic heart failure is admitted with worsening
dyspnea, bibasilar crackles, and 3+ pitting edema. BNP is
markedly elevated. The nurse administers IV furosemide. Which
assessment finding best indicates the medication is having the
intended effect?
A. Decrease in BNP by 50% within 1 hour.
B. Improved oxygenation and decreased crackles on
auscultation. (Correct)
C. Increase in urinary sodium concentration with no change in
urine output.
D. Rise in heart rate by 20 beats/minute.
Rationale (correct — B): Loop diuretics reduce intravascular
volume and pulmonary congestion; an improvement in
oxygenation and fewer crackles indicate reduced pulmonary
edema and effective diuresis. BNP trends are useful but do not
change dramatically within the first hour.
,Why others are incorrect:
A — BNP decreases more slowly over hours to days; an
immediate 50% drop in 1 hour is unrealistic.
C — Increased urine output is expected; sodium concentration
alone without volume change is less clinically useful.
D — An increased heart rate suggests hemodynamic stress or
side effects, not improvement.
3. (Cardiovascular — Dysrhythmia/priority)
A client with new-onset atrial fibrillation has HR 150 bpm and is
hypotensive with dizziness. What is the nurse’s priority action?
A. Administer oral metoprolol as ordered.
B. Prepare for synchronized cardioversion after sedation.
(Correct)
C. Give digoxin and monitor for therapeutic effect.
D. Obtain electrolyte panel and wait for results before
intervening.
Rationale (correct — B): A hemodynamically unstable patient
(hypotension, dizziness) with a rapid ventricular response needs
immediate synchronized cardioversion to restore perfusion.
Stabilization takes precedence over medication therapy.
Why others are incorrect:
A — Beta-blocker may be indicated in a stable patient; in this
unstable scenario, cardioversion is priority.
C — Digoxin has a slow onset and is not appropriate for
immediate rate control in unstable patients.
, D — While electrolytes are important, waiting for labs in an
unstable patient risks further deterioration.
4. (Respiratory — ABG interpretation)
A patient with COPD exacerbation has an arterial blood gas: pH
7.30, PaCO₂ 60 mmHg, HCO₃⁻ 26 mEq/L. Which interpretation is
correct?
A. Uncompensated metabolic acidosis.
B. Respiratory alkalosis with partial compensation.
C. Acute respiratory acidosis. (Correct)
D. Metabolic alkalosis with respiratory compensation.
Rationale (correct — C): Elevated PaCO₂ (60) with low pH (7.30)
and near-normal HCO₃⁻ indicates an acute respiratory acidosis
(hypoventilation/CO₂ retention) without metabolic
compensation. COPD exacerbations commonly cause acute or
chronic respiratory acidosis.
Why others are incorrect:
A — Metabolic acidosis would show low HCO₃⁻.
B — Respiratory alkalosis would show low PaCO₂ and high pH.
D — Metabolic alkalosis would show elevated HCO₃⁻ and high
pH.
5. (Respiratory — Pulmonary embolism)
A postoperative patient develops sudden pleuritic chest pain,
tachycardia, and oxygen desaturation to 86%. Which immediate
