Comprehensive Medical-Surgical Nursing & NCLEX-Style
Prac ce Exam
High-Yield Review — All Major Body Systems
Ques on 1: Autonomic Dysreflexia (Neurological System)
Clinical Scenario: A 32-year-old male pa ent with a T4 spinal cord injury from a prior
motor vehicle accident reports a sudden, crushing frontal headache and severe nasal
conges on. His vital signs reveal a blood pressure of 210/108 mmHg, heart rate of 48
beats/min, and diaphoresis on his forehead and neck while his lower extremi es remain
cool and dry.
Ques on Stem: Which interven on should the nurse perform first?
Op ons:
o A. Elevate the head of the bed to 90 degrees (high-Fowler's posi on).
o B. Palpate the lower abdomen to assess for bladder distension.
o C. Administer intravenous hydralazine as ordered.
o D. Check the pa ent's rectum for fecal impac on using lidocaine jelly.
Answer and Ra onale
Correct Answer: A. Elevate the head of the bed to 90 degrees (high-Fowler's posi on).
Cogni ve Level: Applying
Client Needs Category: Physiological Adapta on
, Main Lesson / Takeaway: Immediately posi oning the pa ent upright u lizes orthosta c
gravity to help rapidly lower dangerously elevated blood pressure in autonomic
dysreflexia.
Detailed Ra onale:
o Correct Explana on: Autonomic dysreflexia is a life-threatening hypertensive
emergency occurring in individuals with spinal cord injuries at or above T6.
Eleva ng the head of the bed to 90 degrees (or si ng the pa ent upright with
legs hanging over the bed) is the immediate priority because it leverages gravity
to induce orthosta c reduc on of intracranial and systemic blood pressure
before inves ga ng or trea ng the underlying cause.
o Op on B Breakdown: While bladder distension is the most common trigger for
autonomic dysreflexia, assessing or catheterizing the bladder is the second
ac on, performed immediately a er posi oning the pa ent upright to reduce
stroke risk.
o Op on C Breakdown: Pharmacotherapy (such as short-ac ng an hypertensives
like hydralazine or nifedipine) is indicated if blood pressure remains severely
elevated a er posi oning and removing noxious s muli, but non-pharmacologic
posi oning is faster and comes first.
o Op on D Breakdown: Checking for fecal impac on is essen al if bladder causes
are ruled out, but rectal digital examina on can provoke further autonomic
response and must be preceded by posi oning and topical anesthe c
applica on.
Ques on 2: Acute Myocardial Infarc on & Nitroglycerin (Cardiovascular System)
Clinical Scenario: A 64-year-old female admi ed with acute coronary syndrome reports
ongoing substernal chest pain rated 8/10. Her blood pressure is 118/74 mmHg, heart
rate is 88 beats/min, and oxygen satura on is 96% on room air. The 12-lead ECG reveals
ST-segment eleva on in leads II, III, and aVF.
, Ques on Stem: Prior to administering sublingual nitroglycerin, which ac on is most
cri cal for the nurse to take?
Op ons:
o A. Ask the pa ent if she has ingested a phosphodiesterase-5 (PDE-5) inhibitor in
the past 24–48 hours.
o B. Apply supplemental oxygen via nasal cannula at 2 L/min.
o C. Obtain a repeat 12-lead ECG to confirm right ventricular involvement.
o D. Draw blood samples for STAT troponin I and CK-MB levels.
Answer and Ra onale
Correct Answer: A. Ask the pa ent if she has ingested a phosphodiesterase-5 (PDE-5)
inhibitor in the past 24–48 hours.
Cogni ve Level: Analyzing
Client Needs Category: Reduc on of Risk Poten al
Main Lesson / Takeaway: Concurrent administra on of nitrates and PDE-5 inhibitors
causes profound, poten ally fatal vasodila on and intractable hypotension.
Detailed Ra onale:
o Correct Explana on: Concomitant use of nitroglycerin and PDE-5 inhibitors (e.g.,
sildenafil, tadalafil) causes synergis c cyclic GMP accumula on, leading to
catastrophic hypotension, myocardial ischemia, and death. Because nitrates
cause systemic venodila on and arterial vasodila on, verifying that the client has
not taken these medica ons within 24 to 48 hours is mandatory before
administra on.
o Op on B Breakdown: Supplemental oxygen is no longer rou nely recommended
for acute coronary syndrome unless the pa ent is hypoxemic ($SpO_2 < 90\%$),
, in respiratory distress, or in heart failure, as hyperoxia can induce coronary
vasoconstric on.
o Op on C Breakdown: An inferior wall MI (ST eleva on in II, III, aVF) should raise
suspicion for right ventricular infarc on (where nitrates must be used with
extreme cau on due to preload dependence), but assessing medica on safety
(PDE-5 inhibitors) takes absolute priority to avoid severe vascular collapse.
o Op on D Breakdown: Cardiac enzymes are diagnos c, but obtaining lab draws
must not delay the immediate safety check required before administering nitrate
therapy.
Ques on 3: Diabe c Ketoacidosis Management (Endocrine System)
Clinical Scenario: A 22-year-old male with type 1 diabetes mellitus is admi ed to the
intensive care unit with Diabe c Ketoacidosis (DKA). His ini al lab values show serum
glucose of 480 mg/dL, arterial pH of 7.15, serum potassium of 5.8 mEq/L, and anion gap
of 22 mEq/L. An intravenous regular insulin infusion and isotonic saline fluid
resuscita on were ini ated. Four hours later, his glucose drops to 230 mg/dL, but his
anion gap remains elevated at 16 mEq/L.
Ques on Stem: Which prescrip on should the nurse an cipate execu ng at this me?
Op ons:
o A. Discon nue the regular insulin infusion and switch to subcutaneous insulin
glargine.
o B. Add 5% or 10% Dextrose to the IV fluid regimen while con nuing the regular
insulin infusion.
o C. Increase the regular insulin infusion rate to clear the remaining ketoacidosis
faster.
o D. Administer IV sodium bicarbonate to restore normal blood pH.
Prac ce Exam
High-Yield Review — All Major Body Systems
Ques on 1: Autonomic Dysreflexia (Neurological System)
Clinical Scenario: A 32-year-old male pa ent with a T4 spinal cord injury from a prior
motor vehicle accident reports a sudden, crushing frontal headache and severe nasal
conges on. His vital signs reveal a blood pressure of 210/108 mmHg, heart rate of 48
beats/min, and diaphoresis on his forehead and neck while his lower extremi es remain
cool and dry.
Ques on Stem: Which interven on should the nurse perform first?
Op ons:
o A. Elevate the head of the bed to 90 degrees (high-Fowler's posi on).
o B. Palpate the lower abdomen to assess for bladder distension.
o C. Administer intravenous hydralazine as ordered.
o D. Check the pa ent's rectum for fecal impac on using lidocaine jelly.
Answer and Ra onale
Correct Answer: A. Elevate the head of the bed to 90 degrees (high-Fowler's posi on).
Cogni ve Level: Applying
Client Needs Category: Physiological Adapta on
, Main Lesson / Takeaway: Immediately posi oning the pa ent upright u lizes orthosta c
gravity to help rapidly lower dangerously elevated blood pressure in autonomic
dysreflexia.
Detailed Ra onale:
o Correct Explana on: Autonomic dysreflexia is a life-threatening hypertensive
emergency occurring in individuals with spinal cord injuries at or above T6.
Eleva ng the head of the bed to 90 degrees (or si ng the pa ent upright with
legs hanging over the bed) is the immediate priority because it leverages gravity
to induce orthosta c reduc on of intracranial and systemic blood pressure
before inves ga ng or trea ng the underlying cause.
o Op on B Breakdown: While bladder distension is the most common trigger for
autonomic dysreflexia, assessing or catheterizing the bladder is the second
ac on, performed immediately a er posi oning the pa ent upright to reduce
stroke risk.
o Op on C Breakdown: Pharmacotherapy (such as short-ac ng an hypertensives
like hydralazine or nifedipine) is indicated if blood pressure remains severely
elevated a er posi oning and removing noxious s muli, but non-pharmacologic
posi oning is faster and comes first.
o Op on D Breakdown: Checking for fecal impac on is essen al if bladder causes
are ruled out, but rectal digital examina on can provoke further autonomic
response and must be preceded by posi oning and topical anesthe c
applica on.
Ques on 2: Acute Myocardial Infarc on & Nitroglycerin (Cardiovascular System)
Clinical Scenario: A 64-year-old female admi ed with acute coronary syndrome reports
ongoing substernal chest pain rated 8/10. Her blood pressure is 118/74 mmHg, heart
rate is 88 beats/min, and oxygen satura on is 96% on room air. The 12-lead ECG reveals
ST-segment eleva on in leads II, III, and aVF.
, Ques on Stem: Prior to administering sublingual nitroglycerin, which ac on is most
cri cal for the nurse to take?
Op ons:
o A. Ask the pa ent if she has ingested a phosphodiesterase-5 (PDE-5) inhibitor in
the past 24–48 hours.
o B. Apply supplemental oxygen via nasal cannula at 2 L/min.
o C. Obtain a repeat 12-lead ECG to confirm right ventricular involvement.
o D. Draw blood samples for STAT troponin I and CK-MB levels.
Answer and Ra onale
Correct Answer: A. Ask the pa ent if she has ingested a phosphodiesterase-5 (PDE-5)
inhibitor in the past 24–48 hours.
Cogni ve Level: Analyzing
Client Needs Category: Reduc on of Risk Poten al
Main Lesson / Takeaway: Concurrent administra on of nitrates and PDE-5 inhibitors
causes profound, poten ally fatal vasodila on and intractable hypotension.
Detailed Ra onale:
o Correct Explana on: Concomitant use of nitroglycerin and PDE-5 inhibitors (e.g.,
sildenafil, tadalafil) causes synergis c cyclic GMP accumula on, leading to
catastrophic hypotension, myocardial ischemia, and death. Because nitrates
cause systemic venodila on and arterial vasodila on, verifying that the client has
not taken these medica ons within 24 to 48 hours is mandatory before
administra on.
o Op on B Breakdown: Supplemental oxygen is no longer rou nely recommended
for acute coronary syndrome unless the pa ent is hypoxemic ($SpO_2 < 90\%$),
, in respiratory distress, or in heart failure, as hyperoxia can induce coronary
vasoconstric on.
o Op on C Breakdown: An inferior wall MI (ST eleva on in II, III, aVF) should raise
suspicion for right ventricular infarc on (where nitrates must be used with
extreme cau on due to preload dependence), but assessing medica on safety
(PDE-5 inhibitors) takes absolute priority to avoid severe vascular collapse.
o Op on D Breakdown: Cardiac enzymes are diagnos c, but obtaining lab draws
must not delay the immediate safety check required before administering nitrate
therapy.
Ques on 3: Diabe c Ketoacidosis Management (Endocrine System)
Clinical Scenario: A 22-year-old male with type 1 diabetes mellitus is admi ed to the
intensive care unit with Diabe c Ketoacidosis (DKA). His ini al lab values show serum
glucose of 480 mg/dL, arterial pH of 7.15, serum potassium of 5.8 mEq/L, and anion gap
of 22 mEq/L. An intravenous regular insulin infusion and isotonic saline fluid
resuscita on were ini ated. Four hours later, his glucose drops to 230 mg/dL, but his
anion gap remains elevated at 16 mEq/L.
Ques on Stem: Which prescrip on should the nurse an cipate execu ng at this me?
Op ons:
o A. Discon nue the regular insulin infusion and switch to subcutaneous insulin
glargine.
o B. Add 5% or 10% Dextrose to the IV fluid regimen while con nuing the regular
insulin infusion.
o C. Increase the regular insulin infusion rate to clear the remaining ketoacidosis
faster.
o D. Administer IV sodium bicarbonate to restore normal blood pH.
