Comprehensive Medical-Surgical Nursing Prac ce Exam
NCLEX-Style / Next-Genera on Clinical Judgment–Focused Ques ons
Ques on 1: Acute Respiratory Failure
Clinical Scenario: A 68-year-old male with a 40-pack-year smoking history is admi ed
with acute exacerba on of COPD. He is restless and confused. Vital signs: HR 112 bpm,
RR 28/min, BP 158/90 mmHg, SpO2 88% on 2L nasal cannula. An arterial blood gas
(ABG) reveals: pH 7.28, PaCO2 62 mmHg, PaO2 58 mmHg, HCO3 28 mEq/L.
Ques on Stem: The nurse an cipates which of the following priority interven ons?
Op ons:
A. Administer a seda ve to decrease his agita on and oxygen demand.
B. Prepare for immediate intuba on and mechanical ven la on.
C. Increase the oxygen flow rate to 4L to improve his SpO2.
D. Apply a non-rebreather mask at 15L for maximum oxygena on.
Correct Answer: B. Prepare for immediate intuba on and mechanical ven la on.
Cogni ve Level: Analyzing
Client Needs Category: Physiological Adapta on
Main Lesson / Takeaway: In COPD pa ents, acute respiratory failure with severe
hypercapnia and acidosis is a failure of the ven lator pump, and the priority is to
support ven la on, o en requiring intuba on.
Detailed Ra onale: The correct answer is B. The pa ent is exhibi ng signs of acute
respiratory failure with hypercapnia (PaCO2 62) and respiratory acidosis (pH 7.28) with a
declining level of consciousness (restlessness/confusion). These are classic indicators
that the pa ent is ring and cannot maintain adequate ven la on. Mechanical
ven la on is the defini ve treatment to rest the respiratory muscles and correct the gas
exchange. A. Administering a seda ve is contraindicated in a pa ent with respiratory
failure as it could further depress the respiratory drive and lead to apnea. C & D.
Increasing oxygen flow (C) or applying a non-rebreather (D) may improve oxygena on
(PaO2) but will not address the primary problem of hypercapnia and may even worsen it
by reducing the hypoxic drive to breathe in a chronic CO2 retainer. The priority is to
ensure effec ve ven la on.
,Ques on 2: Cardiac Pharmacology
Clinical Scenario: A 55-year-old female with heart failure with reduced ejec on frac on
(HFrEF) is prescribed carvedilol. She has a current blood pressure of 98/62 mmHg and a
heart rate of 52 bpm.
Ques on Stem: Which of the following ac ons is most appropriate for the nurse to
take?
Op ons:
A. Administer the medica on as prescribed and monitor for symptoma c bradycardia.
B. Hold the medica on and no fy the healthcare provider of the vital signs.
C. Administer a fluid bolus of 250mL of normal saline to support the blood pressure.
D. Administer the medica on with a small snack to increase absorp on.
Correct Answer: B. Hold the medica on and no fy the healthcare provider of the vital
signs.
Cogni ve Level: Applying
Client Needs Category: Pharmacological and Parenteral Therapies
Main Lesson / Takeaway: Beta-blockers for heart failure should be held if the pa ent
exhibits symptoma c bradycardia or hypotension, and the provider must be no fied
before administering the dose.
Detailed Ra onale: The correct answer is B. Carvedilol is a non-selec ve beta-blocker
that reduces heart rate and blood pressure. The pa ent is symptoma c with a heart rate
of 52 (bradycardia) and a low systolic BP of 98. Giving the medica on could drop her BP
further or compromise cardiac output. A. Administering the medica on is unsafe due to
the pa ent's current hemodynamic status. Monitoring alone without holding the drug is
not a safe ac on. C. A fluid bolus is not an independent nursing ac on and would be
inappropriate without a provider's order, as it could worsen heart failure. D. Carvedilol
should be taken with food to reduce the risk of orthosta c hypotension, but this does
not supersede the safety concern of the current low vitals.
Ques on 3: Endocrine Disorders
Clinical Scenario: A 42-year-old pa ent with type 1 diabetes is brought to the emergency
department by paramedics. He is unresponsive, with a blood glucose reading of "HIGH"
, on the glucometer. He has fruity-smelling breath and Kussmaul respira ons. His skin is
warm and dry.
Ques on Stem: The nurse iden fies this presenta on as indica ve of which condi on
and should an cipate which primary interven on?
Op ons:
A. Hyperosmolar Hyperglycemic State (HHS), requiring a rapid IV fluid bolus.
B. Diabe c Ketoacidosis (DKA), requiring an IV insulin drip and fluid resuscita on.
C. Hypoglycemia, requiring a stat dose of IV dextrose.
D. Lac c acidosis, requiring sodium bicarbonate administra on.
Correct Answer: B. Diabe c Ketoacidosis (DKA), requiring an IV insulin drip and fluid
resuscita on.
Cogni ve Level: Analyzing
Client Needs Category: Physiological Adapta on
Main Lesson / Takeaway: DKA is a life-threatening complica on of type 1 diabetes
characterized by hyperglycemia, ketosis, and metabolic acidosis, treated with fluid
resuscita on and insulin.
Detailed Ra onale: The correct answer is B. The pa ent is exhibi ng classic signs of
DKA: hyperglycemia, fruity breath (ketones), Kussmaul respira ons (compensatory
hyperven la on for metabolic acidosis), and altered mental status. The primary
interven ons are IV fluids to correct dehydra on and an insulin drip to lower blood
glucose and stop ketone produc on. A. HHS is more common in type 2 diabetes and
presents with severe dehydra on but without significant ketosis or acidosis. C. This is a
state of severe hyperglycemia, not hypoglycemia. D. While there is metabolic acidosis,
the root cause is a lack of insulin, and the treatment is not primarily sodium bicarbonate,
which is rarely indicated in DKA.
Ques on 4: Renal & Urinary
Clinical Scenario: A 72-year-old male with chronic kidney disease (CKD) is post-opera ve
day 1 a er a hip replacement. His urine output for the last 8 hours is 180 mL total. His
morning labs show: BUN 52 mg/dL, Crea nine 3.8 mg/dL, Potassium 6.1 mEq/L. He is
receiving IV fluids at 100 mL/hr.
Ques on Stem: The nurse should priori ze which of the following assessments?
, Op ons:
A. Assess the pa ent's pain level and provide PRN analgesia.
B. Assess the patency and placement of the indwelling urinary catheter.
C. Assess the pa ent's daily dietary intake for potassium-rich foods.
D. Assess the pa ent's EKG/telemetry for tall-peaked T-waves.
Correct Answer: D. Assess the pa ent's EKG/telemetry for tall-peaked T-waves.
Cogni ve Level: Evalua ng
Client Needs Category: Reduc on of Risk Poten al
Main Lesson / Takeaway: In a pa ent with CKD and oliguria, a potassium level of 6.1
mEq/L is a cri cal value that can cause lethal cardiac dysrhythmias, necessita ng
immediate EKG monitoring.
Detailed Ra onale: The correct answer is D. The pa ent's low urine output and high
potassium (hyperkalemia) put him at immediate risk for cardiac dysrhythmias. The most
urgent nursing ac on is to assess for EKG changes, which are the earliest indicator of
cardiac toxicity. A. Pain management is important but not the priority over a life-
threatening electrolyte imbalance. B. A catheter issue could be a cause for low output,
but the cri cal lab values make the cardiac assessment the priority. C. Dietary teaching is
an important interven on for the future, but the first step is to assess for immediate life-
threatening complica ons.
Ques on 5: Gastrointes nal
Clinical Scenario: A 38-year-old female presents to the emergency department with
severe, right-upper quadrant pain that radiates to her right shoulder, accompanied by
nausea and vomi ng. She describes the pain as a "10 out of 10" and states that it started
about 3 hours a er ea ng a fa y meal. Her vital signs are: BP 148/92, HR 112, Temp
100.8°F (38.2°C).
Ques on Stem: The nurse suspects cholecys s and should priori ze which of the
following interven ons?
Op ons:
A. Administer a prescribed opioid analgesic and maintain NPO status.
B. Place the pa ent in a high-Fowler's posi on to ease breathing.
C. Administer an an eme c and encourage oral intake of clear liquids.
D. Apply a hea ng pad to the RUQ to help relieve the pain.
NCLEX-Style / Next-Genera on Clinical Judgment–Focused Ques ons
Ques on 1: Acute Respiratory Failure
Clinical Scenario: A 68-year-old male with a 40-pack-year smoking history is admi ed
with acute exacerba on of COPD. He is restless and confused. Vital signs: HR 112 bpm,
RR 28/min, BP 158/90 mmHg, SpO2 88% on 2L nasal cannula. An arterial blood gas
(ABG) reveals: pH 7.28, PaCO2 62 mmHg, PaO2 58 mmHg, HCO3 28 mEq/L.
Ques on Stem: The nurse an cipates which of the following priority interven ons?
Op ons:
A. Administer a seda ve to decrease his agita on and oxygen demand.
B. Prepare for immediate intuba on and mechanical ven la on.
C. Increase the oxygen flow rate to 4L to improve his SpO2.
D. Apply a non-rebreather mask at 15L for maximum oxygena on.
Correct Answer: B. Prepare for immediate intuba on and mechanical ven la on.
Cogni ve Level: Analyzing
Client Needs Category: Physiological Adapta on
Main Lesson / Takeaway: In COPD pa ents, acute respiratory failure with severe
hypercapnia and acidosis is a failure of the ven lator pump, and the priority is to
support ven la on, o en requiring intuba on.
Detailed Ra onale: The correct answer is B. The pa ent is exhibi ng signs of acute
respiratory failure with hypercapnia (PaCO2 62) and respiratory acidosis (pH 7.28) with a
declining level of consciousness (restlessness/confusion). These are classic indicators
that the pa ent is ring and cannot maintain adequate ven la on. Mechanical
ven la on is the defini ve treatment to rest the respiratory muscles and correct the gas
exchange. A. Administering a seda ve is contraindicated in a pa ent with respiratory
failure as it could further depress the respiratory drive and lead to apnea. C & D.
Increasing oxygen flow (C) or applying a non-rebreather (D) may improve oxygena on
(PaO2) but will not address the primary problem of hypercapnia and may even worsen it
by reducing the hypoxic drive to breathe in a chronic CO2 retainer. The priority is to
ensure effec ve ven la on.
,Ques on 2: Cardiac Pharmacology
Clinical Scenario: A 55-year-old female with heart failure with reduced ejec on frac on
(HFrEF) is prescribed carvedilol. She has a current blood pressure of 98/62 mmHg and a
heart rate of 52 bpm.
Ques on Stem: Which of the following ac ons is most appropriate for the nurse to
take?
Op ons:
A. Administer the medica on as prescribed and monitor for symptoma c bradycardia.
B. Hold the medica on and no fy the healthcare provider of the vital signs.
C. Administer a fluid bolus of 250mL of normal saline to support the blood pressure.
D. Administer the medica on with a small snack to increase absorp on.
Correct Answer: B. Hold the medica on and no fy the healthcare provider of the vital
signs.
Cogni ve Level: Applying
Client Needs Category: Pharmacological and Parenteral Therapies
Main Lesson / Takeaway: Beta-blockers for heart failure should be held if the pa ent
exhibits symptoma c bradycardia or hypotension, and the provider must be no fied
before administering the dose.
Detailed Ra onale: The correct answer is B. Carvedilol is a non-selec ve beta-blocker
that reduces heart rate and blood pressure. The pa ent is symptoma c with a heart rate
of 52 (bradycardia) and a low systolic BP of 98. Giving the medica on could drop her BP
further or compromise cardiac output. A. Administering the medica on is unsafe due to
the pa ent's current hemodynamic status. Monitoring alone without holding the drug is
not a safe ac on. C. A fluid bolus is not an independent nursing ac on and would be
inappropriate without a provider's order, as it could worsen heart failure. D. Carvedilol
should be taken with food to reduce the risk of orthosta c hypotension, but this does
not supersede the safety concern of the current low vitals.
Ques on 3: Endocrine Disorders
Clinical Scenario: A 42-year-old pa ent with type 1 diabetes is brought to the emergency
department by paramedics. He is unresponsive, with a blood glucose reading of "HIGH"
, on the glucometer. He has fruity-smelling breath and Kussmaul respira ons. His skin is
warm and dry.
Ques on Stem: The nurse iden fies this presenta on as indica ve of which condi on
and should an cipate which primary interven on?
Op ons:
A. Hyperosmolar Hyperglycemic State (HHS), requiring a rapid IV fluid bolus.
B. Diabe c Ketoacidosis (DKA), requiring an IV insulin drip and fluid resuscita on.
C. Hypoglycemia, requiring a stat dose of IV dextrose.
D. Lac c acidosis, requiring sodium bicarbonate administra on.
Correct Answer: B. Diabe c Ketoacidosis (DKA), requiring an IV insulin drip and fluid
resuscita on.
Cogni ve Level: Analyzing
Client Needs Category: Physiological Adapta on
Main Lesson / Takeaway: DKA is a life-threatening complica on of type 1 diabetes
characterized by hyperglycemia, ketosis, and metabolic acidosis, treated with fluid
resuscita on and insulin.
Detailed Ra onale: The correct answer is B. The pa ent is exhibi ng classic signs of
DKA: hyperglycemia, fruity breath (ketones), Kussmaul respira ons (compensatory
hyperven la on for metabolic acidosis), and altered mental status. The primary
interven ons are IV fluids to correct dehydra on and an insulin drip to lower blood
glucose and stop ketone produc on. A. HHS is more common in type 2 diabetes and
presents with severe dehydra on but without significant ketosis or acidosis. C. This is a
state of severe hyperglycemia, not hypoglycemia. D. While there is metabolic acidosis,
the root cause is a lack of insulin, and the treatment is not primarily sodium bicarbonate,
which is rarely indicated in DKA.
Ques on 4: Renal & Urinary
Clinical Scenario: A 72-year-old male with chronic kidney disease (CKD) is post-opera ve
day 1 a er a hip replacement. His urine output for the last 8 hours is 180 mL total. His
morning labs show: BUN 52 mg/dL, Crea nine 3.8 mg/dL, Potassium 6.1 mEq/L. He is
receiving IV fluids at 100 mL/hr.
Ques on Stem: The nurse should priori ze which of the following assessments?
, Op ons:
A. Assess the pa ent's pain level and provide PRN analgesia.
B. Assess the patency and placement of the indwelling urinary catheter.
C. Assess the pa ent's daily dietary intake for potassium-rich foods.
D. Assess the pa ent's EKG/telemetry for tall-peaked T-waves.
Correct Answer: D. Assess the pa ent's EKG/telemetry for tall-peaked T-waves.
Cogni ve Level: Evalua ng
Client Needs Category: Reduc on of Risk Poten al
Main Lesson / Takeaway: In a pa ent with CKD and oliguria, a potassium level of 6.1
mEq/L is a cri cal value that can cause lethal cardiac dysrhythmias, necessita ng
immediate EKG monitoring.
Detailed Ra onale: The correct answer is D. The pa ent's low urine output and high
potassium (hyperkalemia) put him at immediate risk for cardiac dysrhythmias. The most
urgent nursing ac on is to assess for EKG changes, which are the earliest indicator of
cardiac toxicity. A. Pain management is important but not the priority over a life-
threatening electrolyte imbalance. B. A catheter issue could be a cause for low output,
but the cri cal lab values make the cardiac assessment the priority. C. Dietary teaching is
an important interven on for the future, but the first step is to assess for immediate life-
threatening complica ons.
Ques on 5: Gastrointes nal
Clinical Scenario: A 38-year-old female presents to the emergency department with
severe, right-upper quadrant pain that radiates to her right shoulder, accompanied by
nausea and vomi ng. She describes the pain as a "10 out of 10" and states that it started
about 3 hours a er ea ng a fa y meal. Her vital signs are: BP 148/92, HR 112, Temp
100.8°F (38.2°C).
Ques on Stem: The nurse suspects cholecys s and should priori ze which of the
following interven ons?
Op ons:
A. Administer a prescribed opioid analgesic and maintain NPO status.
B. Place the pa ent in a high-Fowler's posi on to ease breathing.
C. Administer an an eme c and encourage oral intake of clear liquids.
D. Apply a hea ng pad to the RUQ to help relieve the pain.
