Comprehensive Medical-Surgical Nursing Prac ce Exam
NCLEX-RN / NGN Style
Ques on 1: Acute Coronary Syndrome — Priority Assessment
Clinical Scenario: A 68-year-old client with hypertension, hyperlipidemia, and a 40-pack-
year smoking history reports crushing substernal chest pain radia ng to the le arm for
30 minutes. BP is 154/92 mm Hg, HR 104/min, RR 22/min, SpO₂ 93% on room air, and
the ECG shows ST-segment depression in leads V4–V6; ini al high-sensi vity troponin is
elevated.
Ques on Stem: Which nursing ac on is the priority?
Op ons:
o A. Administer prescribed sublingual nitroglycerin and reassess pain and blood
pressure.
o B. Encourage the client to ambulate to improve circula on.
o C. Obtain a fas ng lipid panel before administering medica ons.
o D. Place the client in a supine posi on and begin oral fluids.
Answer and Ra onale
Correct Answer: A. Administer prescribed sublingual nitroglycerin and reassess pain
and blood pressure.
Cogni ve Level: Applying
Client Needs Category: Physiological Adapta on
Main Lesson / Takeaway: In suspected acute coronary syndrome, rapid treatment to
reduce myocardial ischemia takes priority while con nuously monitoring hemodynamic
status.
Detailed Ra onale: Nitroglycerin decreases myocardial oxygen demand and may
improve coronary blood flow, making it an appropriate immediate interven on when
prescribed and when blood pressure is adequate. The nurse should reassess pain, BP,
and overall response a er administra on.
, o B is incorrect: Ambula on increases myocardial oxygen demand and could
worsen ischemia.
o C is incorrect: A lipid panel is important for long-term cardiovascular risk
management but does not take priority over acute ischemia.
o D is incorrect: A supine posi on can increase cardiac workload and aspira on
risk; oral fluids are unnecessary during acute chest pain.
Ques on 2: Heart Failure — Acute Pulmonary Edema
Clinical Scenario: A 74-year-old client with chronic heart failure suddenly develops
severe dyspnea, anxiety, and pink, frothy sputum. BP is 178/96 mm Hg, HR 118/min, RR
32/min, and SpO₂ is 82% despite oxygen at 2 L/min by nasal cannula; bilateral crackles
are audible throughout the lung fields.
Ques on Stem: What should the nurse do first?
Op ons:
o A. Place the client in high-Fowler posi on and increase oxygen support as
prescribed.
o B. Encourage oral fluids to thin respiratory secre ons.
o C. Place the client in a supine posi on to improve venous return.
o D. Obtain the client's daily weight before ini a ng treatment.
Answer and Ra onale
Correct Answer: A. Place the client in high-Fowler posi on and increase oxygen
support as prescribed.
Cogni ve Level: Analyzing
Client Needs Category: Physiological Adapta on
Main Lesson / Takeaway: Acute pulmonary edema is an airway and breathing
emergency requiring immediate op miza on of oxygena on and posi oning.
Detailed Ra onale: Severe hypoxemia and pulmonary edema threaten ven la on and
oxygena on. High-Fowler posi oning reduces venous return and improves lung
expansion, while supplemental oxygen supports oxygena on; addi onal emergency
therapies such as IV diure cs and vasodilators may then be administered as ordered.
, o B is incorrect: Fluids can worsen pulmonary conges on.
o C is incorrect: Supine posi oning increases venous return and can worsen
pulmonary edema.
o D is incorrect: Daily weight is useful for monitoring fluid status but is not
appropriate before addressing severe hypoxemia.
Ques on 3: COPD — Oxygen Therapy
Clinical Scenario: A 71-year-old client with severe COPD is admi ed with worsening
dyspnea and increased sputum produc on. The client is using accessory muscles, has an
RR of 28/min, SpO₂ of 84% on room air, and an arterial blood gas showing pH 7.32,
PaCO₂ 58 mm Hg, and PaO₂ 52 mm Hg.
Ques on Stem: Which interven on should the nurse an cipate?
Op ons:
o A. Administer controlled low-flow oxygen and trate according to the prescribed
target.
o B. Withhold oxygen because supplemental oxygen is contraindicated in COPD.
o C. Apply a nonrebreather mask at maximum flow regardless of oxygen satura on.
o D. Encourage the client to breathe rapidly to eliminate carbon dioxide.
Answer and Ra onale
Correct Answer: A. Administer controlled low-flow oxygen and trate according to the
prescribed target.
Cogni ve Level: Applying
Client Needs Category: Physiological Adapta on
Main Lesson / Takeaway: Clients with COPD and hypoxemia require oxygen, but it
should be carefully trated to the prescribed target while monitoring ven la on and
mental status.
Detailed Ra onale: This client has significant hypoxemia and respiratory acidosis.
Oxygen should not be withheld; controlled oxygen therapy is appropriate with close
monitoring because excessive oxygen administra on can worsen hypercapnia in
suscep ble clients through several physiologic mechanisms.
, o B is incorrect: COPD is not a contraindica on to oxygen therapy.
o C is incorrect: Uncontrolled high-concentra on oxygen is not automa cally
indicated and may worsen CO₂ reten on.
o D is incorrect: Rapid breathing increases respiratory muscle fa gue and does not
reliably correct hypercapnia.
Ques on 4: Pneumonia — Clinical Deteriora on
Clinical Scenario: A 63-year-old client being treated for bacterial pneumonia becomes
increasingly confused and restless. Temperature is 39.1°C (102.4°F), BP is 88/54 mm Hg,
HR is 126/min, RR is 30/min, and SpO₂ is 89% despite oxygen at 4 L/min.
Ques on Stem: Which finding requires the nurse's most immediate response?
Op ons:
o A. Blood pressure of 88/54 mm Hg with acute confusion.
o B. Temperature of 39.1°C (102.4°F).
o C. Produc ve cough with yellow sputum.
o D. Respiratory rate of 30/min.
Answer and Ra onale
Correct Answer: A. Blood pressure of 88/54 mm Hg with acute confusion.
Cogni ve Level: Analyzing
Client Needs Category: Physiological Adapta on
Main Lesson / Takeaway: Hypotension combined with acute mental-status change in an
infected client strongly suggests systemic hypoperfusion and possible sep c shock.
Detailed Ra onale: The combina on of infec on, hypotension, tachycardia, tachypnea,
and acute confusion indicates possible sepsis with impaired ssue perfusion. Immediate
escala on and implementa on of the sepsis protocol are warranted.
o B is incorrect: Fever indicates infec on but is not the most immediately life-
threatening finding.
o C is incorrect: Purulent sputum is consistent with pneumonia.
NCLEX-RN / NGN Style
Ques on 1: Acute Coronary Syndrome — Priority Assessment
Clinical Scenario: A 68-year-old client with hypertension, hyperlipidemia, and a 40-pack-
year smoking history reports crushing substernal chest pain radia ng to the le arm for
30 minutes. BP is 154/92 mm Hg, HR 104/min, RR 22/min, SpO₂ 93% on room air, and
the ECG shows ST-segment depression in leads V4–V6; ini al high-sensi vity troponin is
elevated.
Ques on Stem: Which nursing ac on is the priority?
Op ons:
o A. Administer prescribed sublingual nitroglycerin and reassess pain and blood
pressure.
o B. Encourage the client to ambulate to improve circula on.
o C. Obtain a fas ng lipid panel before administering medica ons.
o D. Place the client in a supine posi on and begin oral fluids.
Answer and Ra onale
Correct Answer: A. Administer prescribed sublingual nitroglycerin and reassess pain
and blood pressure.
Cogni ve Level: Applying
Client Needs Category: Physiological Adapta on
Main Lesson / Takeaway: In suspected acute coronary syndrome, rapid treatment to
reduce myocardial ischemia takes priority while con nuously monitoring hemodynamic
status.
Detailed Ra onale: Nitroglycerin decreases myocardial oxygen demand and may
improve coronary blood flow, making it an appropriate immediate interven on when
prescribed and when blood pressure is adequate. The nurse should reassess pain, BP,
and overall response a er administra on.
, o B is incorrect: Ambula on increases myocardial oxygen demand and could
worsen ischemia.
o C is incorrect: A lipid panel is important for long-term cardiovascular risk
management but does not take priority over acute ischemia.
o D is incorrect: A supine posi on can increase cardiac workload and aspira on
risk; oral fluids are unnecessary during acute chest pain.
Ques on 2: Heart Failure — Acute Pulmonary Edema
Clinical Scenario: A 74-year-old client with chronic heart failure suddenly develops
severe dyspnea, anxiety, and pink, frothy sputum. BP is 178/96 mm Hg, HR 118/min, RR
32/min, and SpO₂ is 82% despite oxygen at 2 L/min by nasal cannula; bilateral crackles
are audible throughout the lung fields.
Ques on Stem: What should the nurse do first?
Op ons:
o A. Place the client in high-Fowler posi on and increase oxygen support as
prescribed.
o B. Encourage oral fluids to thin respiratory secre ons.
o C. Place the client in a supine posi on to improve venous return.
o D. Obtain the client's daily weight before ini a ng treatment.
Answer and Ra onale
Correct Answer: A. Place the client in high-Fowler posi on and increase oxygen
support as prescribed.
Cogni ve Level: Analyzing
Client Needs Category: Physiological Adapta on
Main Lesson / Takeaway: Acute pulmonary edema is an airway and breathing
emergency requiring immediate op miza on of oxygena on and posi oning.
Detailed Ra onale: Severe hypoxemia and pulmonary edema threaten ven la on and
oxygena on. High-Fowler posi oning reduces venous return and improves lung
expansion, while supplemental oxygen supports oxygena on; addi onal emergency
therapies such as IV diure cs and vasodilators may then be administered as ordered.
, o B is incorrect: Fluids can worsen pulmonary conges on.
o C is incorrect: Supine posi oning increases venous return and can worsen
pulmonary edema.
o D is incorrect: Daily weight is useful for monitoring fluid status but is not
appropriate before addressing severe hypoxemia.
Ques on 3: COPD — Oxygen Therapy
Clinical Scenario: A 71-year-old client with severe COPD is admi ed with worsening
dyspnea and increased sputum produc on. The client is using accessory muscles, has an
RR of 28/min, SpO₂ of 84% on room air, and an arterial blood gas showing pH 7.32,
PaCO₂ 58 mm Hg, and PaO₂ 52 mm Hg.
Ques on Stem: Which interven on should the nurse an cipate?
Op ons:
o A. Administer controlled low-flow oxygen and trate according to the prescribed
target.
o B. Withhold oxygen because supplemental oxygen is contraindicated in COPD.
o C. Apply a nonrebreather mask at maximum flow regardless of oxygen satura on.
o D. Encourage the client to breathe rapidly to eliminate carbon dioxide.
Answer and Ra onale
Correct Answer: A. Administer controlled low-flow oxygen and trate according to the
prescribed target.
Cogni ve Level: Applying
Client Needs Category: Physiological Adapta on
Main Lesson / Takeaway: Clients with COPD and hypoxemia require oxygen, but it
should be carefully trated to the prescribed target while monitoring ven la on and
mental status.
Detailed Ra onale: This client has significant hypoxemia and respiratory acidosis.
Oxygen should not be withheld; controlled oxygen therapy is appropriate with close
monitoring because excessive oxygen administra on can worsen hypercapnia in
suscep ble clients through several physiologic mechanisms.
, o B is incorrect: COPD is not a contraindica on to oxygen therapy.
o C is incorrect: Uncontrolled high-concentra on oxygen is not automa cally
indicated and may worsen CO₂ reten on.
o D is incorrect: Rapid breathing increases respiratory muscle fa gue and does not
reliably correct hypercapnia.
Ques on 4: Pneumonia — Clinical Deteriora on
Clinical Scenario: A 63-year-old client being treated for bacterial pneumonia becomes
increasingly confused and restless. Temperature is 39.1°C (102.4°F), BP is 88/54 mm Hg,
HR is 126/min, RR is 30/min, and SpO₂ is 89% despite oxygen at 4 L/min.
Ques on Stem: Which finding requires the nurse's most immediate response?
Op ons:
o A. Blood pressure of 88/54 mm Hg with acute confusion.
o B. Temperature of 39.1°C (102.4°F).
o C. Produc ve cough with yellow sputum.
o D. Respiratory rate of 30/min.
Answer and Ra onale
Correct Answer: A. Blood pressure of 88/54 mm Hg with acute confusion.
Cogni ve Level: Analyzing
Client Needs Category: Physiological Adapta on
Main Lesson / Takeaway: Hypotension combined with acute mental-status change in an
infected client strongly suggests systemic hypoperfusion and possible sep c shock.
Detailed Ra onale: The combina on of infec on, hypotension, tachycardia, tachypnea,
and acute confusion indicates possible sepsis with impaired ssue perfusion. Immediate
escala on and implementa on of the sepsis protocol are warranted.
o B is incorrect: Fever indicates infec on but is not the most immediately life-
threatening finding.
o C is incorrect: Purulent sputum is consistent with pneumonia.
