Comprehensive Medical-Surgical Nursing Prac ce Exam
NCLEX-Style Applica on & Analysis Ques ons
Ques on 1: Acute Respiratory Distress & Airway Management
Clinical Scenario: A 68-year-old male, 2 days post-right total knee arthroplasty, suddenly
complains of sharp right-sided chest pain and shortness of breath. His vital signs are: HR
118 bpm, BP 148/92 mmHg, RR 32/min, SpO2 88% on room air, and temperature 37.2°C
(99.0°F). He is restless and appears anxious. You auscultate his lungs and note clear
breath sounds on the le but diminished breath sounds on the right.
Ques on Stem: What is the nurse's priority ac on?
Op ons:
A. Administer prescribed PRN morphine sulfate 4mg IV push for pain.
B. Apply supplemental oxygen via a non-rebreather mask at 15 L/min.
C. Posi on the pa ent in the high-Fowler's posi on and have him take deep breaths.
D. Prepare for an immediate chest x-ray and no fy the healthcare provider.
Answer and Ra onale
Correct Answer: B. Apply supplemental oxygen via a non-rebreather mask at 15 L/min.
Cogni ve Level: Analyzing
Client Needs Category: Physiological Adapta on
Main Lesson / Takeaway: In a pa ent with sudden respiratory distress and signs of a
pulmonary embolism, the priority interven on is to correct life-threatening hypoxemia
with high-flow oxygen before moving to diagnos c confirma on.
Detailed Ra onale:
o Why B is correct: This pa ent is exhibi ng classic signs of a pulmonary embolism
(PE) following surgery: sudden pleuri c chest pain, tachypnea, tachycardia, and
hypoxemia. According to the ABCs (Airway, Breathing, Circula on), the
immediate priority is to address the life-threatening hypoxemia (SpO2 88%).
Applying a non-rebreather mask delivers the highest concentra on of oxygen,
, maximizing perfusion while the underlying cause is addressed. This is the
absolute first step.
o Why A is incorrect: While managing pain is important, administering an opioid
could further depress the pa ent's respiratory drive, which is already
compromised. Pain management should be addressed a er oxygena on is
stabilized, and with cau on in a pa ent with a poten al PE.
o Why C is incorrect: Posi oning is helpful for lung expansion, but it is not
sufficient to correct profound hypoxemia. The pa ent's oxygen satura on is
cri cally low, requiring immediate supplemental oxygen. High-Fowler's posi on is
a secondary interven on, not the priority.
o Why D is incorrect: No fying the provider and obtaining a chest x-ray are crucial
steps in the diagnos c process. However, they are not the priority ac on. The
nurse must stabilize the pa ent's oxygena on first to prevent further
deteriora on or cardiac arrest before pursuing diagnos cs.
Ques on 2: Cardiac Rhythm Interpreta on & Priori za on
Clinical Scenario: You are monitoring a 72-year-old female on a telemetry unit who was
admi ed with heart failure. She is receiving a con nuous IV infusion of amiodarone.
While checking her morning labs, you observe the following rhythm on the monitor: a
regular rhythm with a heart rate of 44 bpm, and each P wave is followed by a QRS
complex.
Ques on Stem: Which nursing ac on is the priority?
Op ons:
A. Assess the pa ent's blood pressure and level of consciousness.
B. Document the rhythm as sinus bradycardia and con nue to monitor.
C. Stop the amiodarone infusion immediately.
D. Prepare to administer atropine 0.5 mg IV push per protocol.
Answer and Ra onale
Correct Answer: A. Assess the pa ent's blood pressure and level of consciousness.
Cogni ve Level: Analyzing
Client Needs Category: Reduc on of Risk Poten al
, Main Lesson / Takeaway: The priority ac on for any dysrhythmia is to assess the
pa ent's hemodynamic stability, as the treatment depends on the pa ent's symptoms,
not the rhythm alone.
Detailed Ra onale:
o Why A is correct: A heart rate of 44 is sinus bradycardia. However, amiodarone is
an an arrhythmic that can cause bradycardia. The nurse's priority is to evaluate
the pa ent's tolerance to this rate. Assessing for symptoms of decreased cardiac
output (hypotension, dizziness, confusion, chest pain) will determine if the
bradycardia requires urgent interven on or is asymptoma c and can be
monitored.
o Why B is incorrect: Documenta on is important, but it is not the priority. The
nurse must first determine the clinical significance of the rhythm. Automa cally
documen ng and con nuing to monitor without an assessment is unsafe.
o Why C is incorrect: While the amiodarone may be the cause, stopping a
con nuous IV infusion of an an arrhythmic abruptly can cause a rebound
dysrhythmia or acute hypotension. The nurse should assess the pa ent and then
consult the provider if the pa ent is symptoma c; the infusion shouldn't be
stopped without an order unless it's a life-threatening emergency.
o Why D is incorrect: Atropine is the treatment of choice for symptoma c
bradycardia. However, administering it without first assessing the pa ent is an
unsafe nursing ac on. The priority is to determine if the pa ent is symptoma c
before proceeding with a medica on that can have adverse effects (e.g.,
tachycardia).
Ques on 3: Fluid & Electrolyte Balance (Hyperkalemia)
Clinical Scenario: A 65-year-old male with end-stage renal disease (ESRD) on
hemodialysis presents with muscle weakness, nausea, and a heart rate of 52 bpm. His
ECG shows peaked T-waves and a prolonged PR interval. His lab results are back:
potassium 6.8 mEq/L, BUN 68 mg/dL, and crea nine 5.2 mg/dL.
Ques on Stem: The nurse an cipates which priority prescrip on from the healthcare
provider?
Op ons:
A. Prepare for emergent hemodialysis.
, B. Administer oral sodium polystyrene sulfonate.
C. Administer IV 50% dextrose and regular insulin.
D. Administer IV calcium gluconate.
Answer and Ra onale
Correct Answer: D. Administer IV calcium gluconate.
Cogni ve Level: Analyzing
Client Needs Category: Physiological Adapta on
Main Lesson / Takeaway: In severe hyperkalemia with ECG changes, the priority is to
immediately stabilize the cardiac membrane with IV calcium to prevent life-threatening
dysrhythmias.
Detailed Ra onale:
o Why D is correct: The pa ent has a cri cally high potassium level (6.8) and is
exhibi ng ECG changes (peaked T-waves, prolonged PR), indica ng severe
hyperkalemia. The priority is to stabilize the myocardium to prevent ventricular
fibrilla on or asystole. IV calcium gluconate works immediately to antagonize the
effects of potassium on the heart, providing temporary stabiliza on while other
treatments remove the potassium.
o Why A is incorrect: Hemodialysis is the defini ve treatment to remove
potassium from the body, but it takes me to set up and ini ate. Calcium is given
first to provide immediate cardiac protec on while prepara ons for dialysis are
being made.
o Why B is incorrect: Sodium polystyrene sulfonate (Kayexalate) helps remove
potassium from the body via the GI tract, but its onset is slow (hours). It is not
appropriate for acute, life-threatening hyperkalemia with ECG changes.
o Why C is incorrect: IV dextrose and insulin are used to shi potassium into the
cells, temporarily lowering serum levels. This is an important treatment, but it is
not the priority. Calcium is given first to stabilize the heart, followed by
insulin/glucose to shi the potassium.
Ques on 4: Endocrine Disorders (Diabe c Ketoacidosis)
Clinical Scenario: A 24-year-old female with type 1 diabetes mellitus is brought to the
emergency department confused and lethargic. Her family reports she has had a
NCLEX-Style Applica on & Analysis Ques ons
Ques on 1: Acute Respiratory Distress & Airway Management
Clinical Scenario: A 68-year-old male, 2 days post-right total knee arthroplasty, suddenly
complains of sharp right-sided chest pain and shortness of breath. His vital signs are: HR
118 bpm, BP 148/92 mmHg, RR 32/min, SpO2 88% on room air, and temperature 37.2°C
(99.0°F). He is restless and appears anxious. You auscultate his lungs and note clear
breath sounds on the le but diminished breath sounds on the right.
Ques on Stem: What is the nurse's priority ac on?
Op ons:
A. Administer prescribed PRN morphine sulfate 4mg IV push for pain.
B. Apply supplemental oxygen via a non-rebreather mask at 15 L/min.
C. Posi on the pa ent in the high-Fowler's posi on and have him take deep breaths.
D. Prepare for an immediate chest x-ray and no fy the healthcare provider.
Answer and Ra onale
Correct Answer: B. Apply supplemental oxygen via a non-rebreather mask at 15 L/min.
Cogni ve Level: Analyzing
Client Needs Category: Physiological Adapta on
Main Lesson / Takeaway: In a pa ent with sudden respiratory distress and signs of a
pulmonary embolism, the priority interven on is to correct life-threatening hypoxemia
with high-flow oxygen before moving to diagnos c confirma on.
Detailed Ra onale:
o Why B is correct: This pa ent is exhibi ng classic signs of a pulmonary embolism
(PE) following surgery: sudden pleuri c chest pain, tachypnea, tachycardia, and
hypoxemia. According to the ABCs (Airway, Breathing, Circula on), the
immediate priority is to address the life-threatening hypoxemia (SpO2 88%).
Applying a non-rebreather mask delivers the highest concentra on of oxygen,
, maximizing perfusion while the underlying cause is addressed. This is the
absolute first step.
o Why A is incorrect: While managing pain is important, administering an opioid
could further depress the pa ent's respiratory drive, which is already
compromised. Pain management should be addressed a er oxygena on is
stabilized, and with cau on in a pa ent with a poten al PE.
o Why C is incorrect: Posi oning is helpful for lung expansion, but it is not
sufficient to correct profound hypoxemia. The pa ent's oxygen satura on is
cri cally low, requiring immediate supplemental oxygen. High-Fowler's posi on is
a secondary interven on, not the priority.
o Why D is incorrect: No fying the provider and obtaining a chest x-ray are crucial
steps in the diagnos c process. However, they are not the priority ac on. The
nurse must stabilize the pa ent's oxygena on first to prevent further
deteriora on or cardiac arrest before pursuing diagnos cs.
Ques on 2: Cardiac Rhythm Interpreta on & Priori za on
Clinical Scenario: You are monitoring a 72-year-old female on a telemetry unit who was
admi ed with heart failure. She is receiving a con nuous IV infusion of amiodarone.
While checking her morning labs, you observe the following rhythm on the monitor: a
regular rhythm with a heart rate of 44 bpm, and each P wave is followed by a QRS
complex.
Ques on Stem: Which nursing ac on is the priority?
Op ons:
A. Assess the pa ent's blood pressure and level of consciousness.
B. Document the rhythm as sinus bradycardia and con nue to monitor.
C. Stop the amiodarone infusion immediately.
D. Prepare to administer atropine 0.5 mg IV push per protocol.
Answer and Ra onale
Correct Answer: A. Assess the pa ent's blood pressure and level of consciousness.
Cogni ve Level: Analyzing
Client Needs Category: Reduc on of Risk Poten al
, Main Lesson / Takeaway: The priority ac on for any dysrhythmia is to assess the
pa ent's hemodynamic stability, as the treatment depends on the pa ent's symptoms,
not the rhythm alone.
Detailed Ra onale:
o Why A is correct: A heart rate of 44 is sinus bradycardia. However, amiodarone is
an an arrhythmic that can cause bradycardia. The nurse's priority is to evaluate
the pa ent's tolerance to this rate. Assessing for symptoms of decreased cardiac
output (hypotension, dizziness, confusion, chest pain) will determine if the
bradycardia requires urgent interven on or is asymptoma c and can be
monitored.
o Why B is incorrect: Documenta on is important, but it is not the priority. The
nurse must first determine the clinical significance of the rhythm. Automa cally
documen ng and con nuing to monitor without an assessment is unsafe.
o Why C is incorrect: While the amiodarone may be the cause, stopping a
con nuous IV infusion of an an arrhythmic abruptly can cause a rebound
dysrhythmia or acute hypotension. The nurse should assess the pa ent and then
consult the provider if the pa ent is symptoma c; the infusion shouldn't be
stopped without an order unless it's a life-threatening emergency.
o Why D is incorrect: Atropine is the treatment of choice for symptoma c
bradycardia. However, administering it without first assessing the pa ent is an
unsafe nursing ac on. The priority is to determine if the pa ent is symptoma c
before proceeding with a medica on that can have adverse effects (e.g.,
tachycardia).
Ques on 3: Fluid & Electrolyte Balance (Hyperkalemia)
Clinical Scenario: A 65-year-old male with end-stage renal disease (ESRD) on
hemodialysis presents with muscle weakness, nausea, and a heart rate of 52 bpm. His
ECG shows peaked T-waves and a prolonged PR interval. His lab results are back:
potassium 6.8 mEq/L, BUN 68 mg/dL, and crea nine 5.2 mg/dL.
Ques on Stem: The nurse an cipates which priority prescrip on from the healthcare
provider?
Op ons:
A. Prepare for emergent hemodialysis.
, B. Administer oral sodium polystyrene sulfonate.
C. Administer IV 50% dextrose and regular insulin.
D. Administer IV calcium gluconate.
Answer and Ra onale
Correct Answer: D. Administer IV calcium gluconate.
Cogni ve Level: Analyzing
Client Needs Category: Physiological Adapta on
Main Lesson / Takeaway: In severe hyperkalemia with ECG changes, the priority is to
immediately stabilize the cardiac membrane with IV calcium to prevent life-threatening
dysrhythmias.
Detailed Ra onale:
o Why D is correct: The pa ent has a cri cally high potassium level (6.8) and is
exhibi ng ECG changes (peaked T-waves, prolonged PR), indica ng severe
hyperkalemia. The priority is to stabilize the myocardium to prevent ventricular
fibrilla on or asystole. IV calcium gluconate works immediately to antagonize the
effects of potassium on the heart, providing temporary stabiliza on while other
treatments remove the potassium.
o Why A is incorrect: Hemodialysis is the defini ve treatment to remove
potassium from the body, but it takes me to set up and ini ate. Calcium is given
first to provide immediate cardiac protec on while prepara ons for dialysis are
being made.
o Why B is incorrect: Sodium polystyrene sulfonate (Kayexalate) helps remove
potassium from the body via the GI tract, but its onset is slow (hours). It is not
appropriate for acute, life-threatening hyperkalemia with ECG changes.
o Why C is incorrect: IV dextrose and insulin are used to shi potassium into the
cells, temporarily lowering serum levels. This is an important treatment, but it is
not the priority. Calcium is given first to stabilize the heart, followed by
insulin/glucose to shi the potassium.
Ques on 4: Endocrine Disorders (Diabe c Ketoacidosis)
Clinical Scenario: A 24-year-old female with type 1 diabetes mellitus is brought to the
emergency department confused and lethargic. Her family reports she has had a
