Comprehensive Medical-Surgical Nursing Prac ce Exam
(NCLEX-RN / NGN Style)
Ques on 1: Cardiovascular System – Acute Coronary Syndrome & Complica ons
Clinical Scenario: A 62-year-old male client with a history of hypertension and
hyperlipidemia is admi ed to the progressive care unit with substernal chest pain
radia ng to his le jaw. Two hours post-percutaneous coronary interven on (PCI) with
stent placement via the right femoral artery, the client reports sudden-onset severe back
and flank pain. Vital signs reveal: blood pressure 84/50 mmHg, heart rate 118 beats/min
(sinus tachycardia), respiratory rate 22 breaths/min, and oxygen satura on 96% on room
air. The right groin puncture site dressing is dry and intact without visible swelling or
hematoma.
Ques on Stem: Which nursing interven on is the absolute priority for this client?
Op ons:
o A. Apply manual firm pressure 2 cm proximal to the femoral puncture site.
o B. Perform a focused vascular assessment of the right lower extremity.
o C. Perform a manual blood pressure check on the opposite arm and no fy the
healthcare provider.
o D. Administer a 500 mL normal saline intravenous bolus immediately as ordered
for hypotension.
Answer and Ra onale
Correct Answer: C – Perform a manual blood pressure check on the opposite arm and
no fy the healthcare provider.
Cogni ve Level: Analyzing
Client Needs Category: Physiological Adapta on / Reduc on of Risk Poten al
Main Lesson / Takeaway: Severe flank or back pain combined with hemodynamic
instability following femoral artery catheteriza on is a hallmark indicator of
retroperitoneal hemorrhage, requiring immediate verifica on and provider no fica on.
Detailed Ra onale:
, o Why Correct: Retroperitoneal bleeding is a life-threatening vascular complica on
of transfemoral cardiac catheteriza on. Because retroperitoneal accumula on
occurs deep in the pelvic space, visible bleeding or hematoma at the puncture
site is frequently absent. The classic presenta on includes severe lower
back/flank pain, hypotension, and tachycardia. The nurse must quickly confirm
true hypotension and immediately alert the interven onal cardiologist/provider
for emergency diagnos c imaging (CT scan) and surgical or angiographic
interven on.
o Distractor Breakdown:
Op on A: Manual pressure proximal to the puncture site is indicated for
an external femoral hematoma or overt arterial site bleeding. It will not
compress retroperitoneal arterial bleeding origina ng higher in the iliac
arterial network.
Op on B: Assessing distal lower extremity pulses (pedal/posterior bial)
is standard post-PCI care, but in the presence of acute retroperitoneal
shock, verifying hypotension and ini a ng emergency no fica on takes
precedence over rou ne pulse mapping.
Op on D: While fluid resuscita on will ul mately be required,
administering fluids without immediately no fying the interven onal
team delays defini ve repair of an ac ve retroperitoneal bleed.
Ques on 2: Cardiovascular System – Acute Decompensated Heart Failure & Pharmacology
Clinical Scenario: A 71-year-old female client with severe systolic heart failure (ejec on
frac on 22%) is receiving a con nuous intravenous infusion of furosemide (10 mg/hr)
and digoxin (0.125 mg oral daily). During morning rounds, the client complains of
nausea, anorexia, and seeing "yellowish-green halos" around the bedside light fixtures.
Morning laboratory results display: sodium 136 mEq/L, potassium 3.1 mEq/L,
magnesium 1.4 mEq/L, serum crea nine 1.9 mg/dL, and blood urea nitrogen (BUN)
38 mg/dL.
Ques on Stem: Which clinical ac on should the nurse take first?
Op ons:
o A. Administer the scheduled morning dose of oral digoxin with a glass of water.
o B. Withhold the digoxin dose and request a serum potassium and digoxin level
order.
, o C. Administer an intravenous an eme c to relieve the client's nausea.
o D. Increase the con nuous furosemide infusion rate to enhance fluid clearance.
Answer and Ra onale
Correct Answer: B – Withhold the digoxin dose and request a serum potassium and
digoxin level order.
Cogni ve Level: Analyzing
Client Needs Category: Pharmacological and Parenteral Therapies
Main Lesson / Takeaway: Hypokalemia and hypomagnesemia significantly poten ate
digoxin toxicity; visual disturbances and gastrointes nal distress mandate immediate
withholding of the drug and serum level evalua on.
Detailed Ra onale:
o Why Correct: The client is demonstra ng classic signs of digitalis toxicity
(gastrointes nal disturbance like nausea/anorexia and visual changes like
xanthopsia/yellow-green halos). Hypokalemia (3.1 mEq/L) greatly sensi zes the
myocardium to digoxin, increasing the risk of lethal cardiac dysrhythmias (e.g.,
ventricular tachycardia, complete heart block). Serum crea nine eleva on also
points to impaired renal elimina on of digoxin. The primary ac on is to hold the
medica on and no fy the provider while obtaining serum electrolyte and digoxin
concentra ons.
o Distractor Breakdown:
Op on A: Administering digoxin in a client exhibi ng ac ve toxic
symptoms and uncorrected hypokalemia could induce life-threatening
dysrhythmias.
Op on C: Trea ng nausea symptoma cally with an an eme c masks a
key diagnos c indicator of digoxin toxicity without addressing the
underlying electrolyte imbalance or drug toxicity.
Op on D: Increasing loop diure c (furosemide) administra on will
exacerbate renal insufficiency, hypokalemia, and hypomagnesemia,
further worsening digoxin toxicity.
Ques on 3: Respiratory System – Acute Respiratory Distress Syndrome (ARDS) & Mechanical
Ven la on
, Clinical Scenario: A 48-year-old male client with severe acute pancrea s develops
Acute Respiratory Distress Syndrome (ARDS) and is intubated and mechanically
ven lated on Volume Control mode. Current ven lator se ngs and arterial blood gas
(ABG) values are: FiO2 0.70, Posi ve End-Expiratory Pressure (PEEP) 14 cmH2O, Tidal
Volume 380 mL (6 mL/kg IBW). ABG results: pH 7.31, PaCO2 48 mmHg, PaO2 54 mmHg,
HCO3− 24 mEq/L. The nurse notes the ven lator's high-peak airway pressure alarm
con nuously sounding, and tracheal devia on to the right side is observed upon physical
examina on.
Ques on Stem: What is the nurse's immediate priority interven on?
Op ons:
o A. Increase the ven lator FiO2 se ng to 1.0 (100%).
o B. Perform inline endotracheal suc oning to clear thick pulmonary secre ons.
o C. Disconnect the client from the ven lator and manually bag with 100% oxygen
while preparing for emergency needle decompression.
o D. Administer a bolus of intravenous neuromuscular blocking agent
(cisatracurium).
Answer and Ra onale
Correct Answer: C – Disconnect the client from the ven lator and manually bag with
100% oxygen while preparing for emergency needle decompression.
Cogni ve Level: Evalua ng
Client Needs Category: Physiological Adapta on / Reduc on of Risk Poten al
Main Lesson / Takeaway: High PEEP levels in ARDS carry a major risk of barotrauma
resul ng in tension pneumothorax, characterized by sudden high peak pressures,
hypoxia, and tracheal devia on.
Detailed Ra onale:
o Why Correct: High PEEP (14 cmH2O) combined with non-compliant lungs in
ARDS increases alveolar rupture risk leading to tension pneumothorax. Tracheal
devia on away from the affected side (rightward devia on indicates le -sided
pneumothorax), combined with sudden high-pressure alarms and persistent
severe hypoxemia (PaO2 54 mmHg on 70%FiO2), signals a tension
pneumothorax. This is a life-threatening emergency causing obstruc ve shock.
(NCLEX-RN / NGN Style)
Ques on 1: Cardiovascular System – Acute Coronary Syndrome & Complica ons
Clinical Scenario: A 62-year-old male client with a history of hypertension and
hyperlipidemia is admi ed to the progressive care unit with substernal chest pain
radia ng to his le jaw. Two hours post-percutaneous coronary interven on (PCI) with
stent placement via the right femoral artery, the client reports sudden-onset severe back
and flank pain. Vital signs reveal: blood pressure 84/50 mmHg, heart rate 118 beats/min
(sinus tachycardia), respiratory rate 22 breaths/min, and oxygen satura on 96% on room
air. The right groin puncture site dressing is dry and intact without visible swelling or
hematoma.
Ques on Stem: Which nursing interven on is the absolute priority for this client?
Op ons:
o A. Apply manual firm pressure 2 cm proximal to the femoral puncture site.
o B. Perform a focused vascular assessment of the right lower extremity.
o C. Perform a manual blood pressure check on the opposite arm and no fy the
healthcare provider.
o D. Administer a 500 mL normal saline intravenous bolus immediately as ordered
for hypotension.
Answer and Ra onale
Correct Answer: C – Perform a manual blood pressure check on the opposite arm and
no fy the healthcare provider.
Cogni ve Level: Analyzing
Client Needs Category: Physiological Adapta on / Reduc on of Risk Poten al
Main Lesson / Takeaway: Severe flank or back pain combined with hemodynamic
instability following femoral artery catheteriza on is a hallmark indicator of
retroperitoneal hemorrhage, requiring immediate verifica on and provider no fica on.
Detailed Ra onale:
, o Why Correct: Retroperitoneal bleeding is a life-threatening vascular complica on
of transfemoral cardiac catheteriza on. Because retroperitoneal accumula on
occurs deep in the pelvic space, visible bleeding or hematoma at the puncture
site is frequently absent. The classic presenta on includes severe lower
back/flank pain, hypotension, and tachycardia. The nurse must quickly confirm
true hypotension and immediately alert the interven onal cardiologist/provider
for emergency diagnos c imaging (CT scan) and surgical or angiographic
interven on.
o Distractor Breakdown:
Op on A: Manual pressure proximal to the puncture site is indicated for
an external femoral hematoma or overt arterial site bleeding. It will not
compress retroperitoneal arterial bleeding origina ng higher in the iliac
arterial network.
Op on B: Assessing distal lower extremity pulses (pedal/posterior bial)
is standard post-PCI care, but in the presence of acute retroperitoneal
shock, verifying hypotension and ini a ng emergency no fica on takes
precedence over rou ne pulse mapping.
Op on D: While fluid resuscita on will ul mately be required,
administering fluids without immediately no fying the interven onal
team delays defini ve repair of an ac ve retroperitoneal bleed.
Ques on 2: Cardiovascular System – Acute Decompensated Heart Failure & Pharmacology
Clinical Scenario: A 71-year-old female client with severe systolic heart failure (ejec on
frac on 22%) is receiving a con nuous intravenous infusion of furosemide (10 mg/hr)
and digoxin (0.125 mg oral daily). During morning rounds, the client complains of
nausea, anorexia, and seeing "yellowish-green halos" around the bedside light fixtures.
Morning laboratory results display: sodium 136 mEq/L, potassium 3.1 mEq/L,
magnesium 1.4 mEq/L, serum crea nine 1.9 mg/dL, and blood urea nitrogen (BUN)
38 mg/dL.
Ques on Stem: Which clinical ac on should the nurse take first?
Op ons:
o A. Administer the scheduled morning dose of oral digoxin with a glass of water.
o B. Withhold the digoxin dose and request a serum potassium and digoxin level
order.
, o C. Administer an intravenous an eme c to relieve the client's nausea.
o D. Increase the con nuous furosemide infusion rate to enhance fluid clearance.
Answer and Ra onale
Correct Answer: B – Withhold the digoxin dose and request a serum potassium and
digoxin level order.
Cogni ve Level: Analyzing
Client Needs Category: Pharmacological and Parenteral Therapies
Main Lesson / Takeaway: Hypokalemia and hypomagnesemia significantly poten ate
digoxin toxicity; visual disturbances and gastrointes nal distress mandate immediate
withholding of the drug and serum level evalua on.
Detailed Ra onale:
o Why Correct: The client is demonstra ng classic signs of digitalis toxicity
(gastrointes nal disturbance like nausea/anorexia and visual changes like
xanthopsia/yellow-green halos). Hypokalemia (3.1 mEq/L) greatly sensi zes the
myocardium to digoxin, increasing the risk of lethal cardiac dysrhythmias (e.g.,
ventricular tachycardia, complete heart block). Serum crea nine eleva on also
points to impaired renal elimina on of digoxin. The primary ac on is to hold the
medica on and no fy the provider while obtaining serum electrolyte and digoxin
concentra ons.
o Distractor Breakdown:
Op on A: Administering digoxin in a client exhibi ng ac ve toxic
symptoms and uncorrected hypokalemia could induce life-threatening
dysrhythmias.
Op on C: Trea ng nausea symptoma cally with an an eme c masks a
key diagnos c indicator of digoxin toxicity without addressing the
underlying electrolyte imbalance or drug toxicity.
Op on D: Increasing loop diure c (furosemide) administra on will
exacerbate renal insufficiency, hypokalemia, and hypomagnesemia,
further worsening digoxin toxicity.
Ques on 3: Respiratory System – Acute Respiratory Distress Syndrome (ARDS) & Mechanical
Ven la on
, Clinical Scenario: A 48-year-old male client with severe acute pancrea s develops
Acute Respiratory Distress Syndrome (ARDS) and is intubated and mechanically
ven lated on Volume Control mode. Current ven lator se ngs and arterial blood gas
(ABG) values are: FiO2 0.70, Posi ve End-Expiratory Pressure (PEEP) 14 cmH2O, Tidal
Volume 380 mL (6 mL/kg IBW). ABG results: pH 7.31, PaCO2 48 mmHg, PaO2 54 mmHg,
HCO3− 24 mEq/L. The nurse notes the ven lator's high-peak airway pressure alarm
con nuously sounding, and tracheal devia on to the right side is observed upon physical
examina on.
Ques on Stem: What is the nurse's immediate priority interven on?
Op ons:
o A. Increase the ven lator FiO2 se ng to 1.0 (100%).
o B. Perform inline endotracheal suc oning to clear thick pulmonary secre ons.
o C. Disconnect the client from the ven lator and manually bag with 100% oxygen
while preparing for emergency needle decompression.
o D. Administer a bolus of intravenous neuromuscular blocking agent
(cisatracurium).
Answer and Ra onale
Correct Answer: C – Disconnect the client from the ven lator and manually bag with
100% oxygen while preparing for emergency needle decompression.
Cogni ve Level: Evalua ng
Client Needs Category: Physiological Adapta on / Reduc on of Risk Poten al
Main Lesson / Takeaway: High PEEP levels in ARDS carry a major risk of barotrauma
resul ng in tension pneumothorax, characterized by sudden high peak pressures,
hypoxia, and tracheal devia on.
Detailed Ra onale:
o Why Correct: High PEEP (14 cmH2O) combined with non-compliant lungs in
ARDS increases alveolar rupture risk leading to tension pneumothorax. Tracheal
devia on away from the affected side (rightward devia on indicates le -sided
pneumothorax), combined with sudden high-pressure alarms and persistent
severe hypoxemia (PaO2 54 mmHg on 70%FiO2), signals a tension
pneumothorax. This is a life-threatening emergency causing obstruc ve shock.
