Clinical Decision-Making in Med-Surg – Practice
Exam (150 Q&A)
1. A patient with heart failure reports sudden weight gain of 3 kg in
2 days. Which is the priority nursing action?
Assess for signs of fluid overload such as edema and dyspnea.
Rationale: Sudden weight gain indicates fluid retention. Early
assessment prevents complications like pulmonary edema.
2. A post-operative patient develops sudden shortness of breath and
pleuritic chest pain. What is the immediate nursing action?
Notify the rapid response team or physician for possible
pulmonary embolism.
Rationale: These are classic signs of PE, a life-threatening
condition requiring urgent intervention.
3. A patient with type 2 diabetes presents with confusion, sweating,
and tremors. Which action should the nurse take first?
Check blood glucose immediately.
Rationale: Symptoms indicate hypoglycemia; prompt
measurement guides rapid treatment to prevent seizures or
coma.
4. A patient with COPD is receiving oxygen at 2 L/min. The nurse
notices increased drowsiness and CO2 retention on ABGs. What
should the nurse do?
Reduce oxygen flow and notify the physician.
Rationale: Excess oxygen can depress the hypoxic drive in COPD
patients, worsening hypercapnia.
,5. A patient with chronic kidney disease has serum potassium of 6.2
mEq/L. Which action is priority?
Notify the physician immediately and prepare for interventions
to lower potassium.
Rationale: Hyperkalemia can cause life-threatening cardiac
arrhythmias; prompt management is critical.
6. A patient reports sudden right-sided weakness and slurred
speech. What is the first nursing action?
Activate the stroke protocol and notify the physician
immediately.
Rationale: Time-sensitive interventions for stroke can reduce
permanent neurologic damage.
7. A patient receiving IV vancomycin develops redness and itching
along the infusion site. What should the nurse do?
Stop the infusion, assess for reaction, and notify the physician.
Rationale: Red man syndrome is a histamine-mediated reaction
that requires slowing or stopping the infusion.
8. A patient with pneumonia has oxygen saturation of 88% on room
air. Which action should the nurse take?
Administer supplemental oxygen as prescribed and monitor
response.
Rationale: Hypoxemia requires immediate oxygen therapy to
maintain tissue perfusion.
9. A patient with a history of DVT is prescribed heparin. Which lab
test should the nurse monitor?
Activated partial thromboplastin time (aPTT).
Rationale: aPTT assesses therapeutic anticoagulation with
heparin to prevent bleeding or clotting complications.
, 10. A patient has postoperative confusion and restlessness. Vital
signs show BP 180/100 mmHg, HR 110, and temperature 38.5°C.
What is the priority action?
Assess for postoperative complications such as infection,
hypoxia, or pain.
Rationale: Confusion may indicate underlying complications that
require immediate evaluation and treatment.
11. A patient with a myocardial infarction is prescribed
nitroglycerin sublingually for chest pain. The nurse should instruct
the patient to:
Take one tablet and repeat every 5 minutes as needed, up to 3
doses, while sitting or lying down.
Rationale: Proper administration prevents hypotension and
ensures efficacy.
12. A patient with acute pancreatitis reports severe abdominal
pain unrelieved by morphine. What is the best nursing action?
Assess for complications such as pancreatic necrosis or
pseudocyst formation.
Rationale: Worsening pain may indicate serious complications
requiring urgent evaluation.
13. A patient with cirrhosis presents with ascites and shortness
of breath. Which intervention should the nurse prioritize?
Assess respiratory status and prepare for paracentesis if
indicated.
Rationale: Ascites can impair breathing; monitoring and
managing fluid accumulation prevents respiratory compromise.
14. A patient receiving chemotherapy reports oral mucositis.
Which intervention is appropriate?
Encourage gentle oral care with a soft toothbrush and non-
Exam (150 Q&A)
1. A patient with heart failure reports sudden weight gain of 3 kg in
2 days. Which is the priority nursing action?
Assess for signs of fluid overload such as edema and dyspnea.
Rationale: Sudden weight gain indicates fluid retention. Early
assessment prevents complications like pulmonary edema.
2. A post-operative patient develops sudden shortness of breath and
pleuritic chest pain. What is the immediate nursing action?
Notify the rapid response team or physician for possible
pulmonary embolism.
Rationale: These are classic signs of PE, a life-threatening
condition requiring urgent intervention.
3. A patient with type 2 diabetes presents with confusion, sweating,
and tremors. Which action should the nurse take first?
Check blood glucose immediately.
Rationale: Symptoms indicate hypoglycemia; prompt
measurement guides rapid treatment to prevent seizures or
coma.
4. A patient with COPD is receiving oxygen at 2 L/min. The nurse
notices increased drowsiness and CO2 retention on ABGs. What
should the nurse do?
Reduce oxygen flow and notify the physician.
Rationale: Excess oxygen can depress the hypoxic drive in COPD
patients, worsening hypercapnia.
,5. A patient with chronic kidney disease has serum potassium of 6.2
mEq/L. Which action is priority?
Notify the physician immediately and prepare for interventions
to lower potassium.
Rationale: Hyperkalemia can cause life-threatening cardiac
arrhythmias; prompt management is critical.
6. A patient reports sudden right-sided weakness and slurred
speech. What is the first nursing action?
Activate the stroke protocol and notify the physician
immediately.
Rationale: Time-sensitive interventions for stroke can reduce
permanent neurologic damage.
7. A patient receiving IV vancomycin develops redness and itching
along the infusion site. What should the nurse do?
Stop the infusion, assess for reaction, and notify the physician.
Rationale: Red man syndrome is a histamine-mediated reaction
that requires slowing or stopping the infusion.
8. A patient with pneumonia has oxygen saturation of 88% on room
air. Which action should the nurse take?
Administer supplemental oxygen as prescribed and monitor
response.
Rationale: Hypoxemia requires immediate oxygen therapy to
maintain tissue perfusion.
9. A patient with a history of DVT is prescribed heparin. Which lab
test should the nurse monitor?
Activated partial thromboplastin time (aPTT).
Rationale: aPTT assesses therapeutic anticoagulation with
heparin to prevent bleeding or clotting complications.
, 10. A patient has postoperative confusion and restlessness. Vital
signs show BP 180/100 mmHg, HR 110, and temperature 38.5°C.
What is the priority action?
Assess for postoperative complications such as infection,
hypoxia, or pain.
Rationale: Confusion may indicate underlying complications that
require immediate evaluation and treatment.
11. A patient with a myocardial infarction is prescribed
nitroglycerin sublingually for chest pain. The nurse should instruct
the patient to:
Take one tablet and repeat every 5 minutes as needed, up to 3
doses, while sitting or lying down.
Rationale: Proper administration prevents hypotension and
ensures efficacy.
12. A patient with acute pancreatitis reports severe abdominal
pain unrelieved by morphine. What is the best nursing action?
Assess for complications such as pancreatic necrosis or
pseudocyst formation.
Rationale: Worsening pain may indicate serious complications
requiring urgent evaluation.
13. A patient with cirrhosis presents with ascites and shortness
of breath. Which intervention should the nurse prioritize?
Assess respiratory status and prepare for paracentesis if
indicated.
Rationale: Ascites can impair breathing; monitoring and
managing fluid accumulation prevents respiratory compromise.
14. A patient receiving chemotherapy reports oral mucositis.
Which intervention is appropriate?
Encourage gentle oral care with a soft toothbrush and non-
