MED_SURG_NCLEX_PRACTICE_EXAM.
Ques on 1: Acute Coronary Syndrome — Priority Interven on
Clinical Scenario: A 68-year-old client with a history of hypertension and hyperlipidemia
reports crushing substernal chest pain radia ng to the le arm for 30 minutes. BP is
156/92 mmHg, HR 104/min, RR 22/min, SpO₂ 91% on room air, and ECG shows ST-
segment eleva on in leads II, III, and aVF. The client is diaphore c and nauseated.
Ques on Stem: Which ac on should the nurse take first?
Op ons:
o A. Administer prescribed sublingual nitroglycerin.
o B. Apply supplemental oxygen.
o C. Obtain a 12-lead ECG and no fy the provider.
o D. Administer prescribed IV morphine.
Answer and Ra onale
Correct Answer: B. Apply supplemental oxygen.
Cogni ve Level: Analyzing
Client Needs Category: Physiological Adapta on
Main Lesson / Takeaway: In acute coronary syndrome, immediate correc on of clinically
significant hypoxemia takes priority while defini ve reperfusion therapy is arranged.
Detailed Ra onale: The client has acute myocardial infarc on findings with an SpO₂ of
91% and respiratory distress, making oxygena on an immediate priority under the ABC
framework. Supplemental oxygen is appropriate when the client is hypoxemic;
meanwhile, the nurse should rapidly ac vate the acute coronary syndrome protocol and
prepare for reperfusion.
o A. Nitroglycerin reduces myocardial oxygen demand and may relieve ischemic
pain, but correc ng hypoxemia takes priority.
o C. A 12-lead ECG is essen al, but the scenario already provides diagnos c ECG
findings; oxygena on is the immediate concern.
, o D. Morphine may be considered for persistent severe pain but is not the first
interven on when hypoxemia is present.
Ques on 2: Acute Ischemic Stroke — Thromboly c Safety
Clinical Scenario: A 72-year-old client develops sudden right-sided weakness and
expressive aphasia while ea ng breakfast. Symptoms began 75 minutes ago, BP is
174/96 mmHg, blood glucose is 108 mg/dL, and the client takes warfarin for atrial
fibrilla on.
Ques on Stem: Which assessment finding is most important for the nurse to obtain
before thromboly c therapy is considered?
Op ons:
o A. Current interna onal normalized ra o (INR).
o B. Serum sodium concentra on.
o C. Hemoglobin A1c level.
o D. Current LDL cholesterol level.
Answer and Ra onale
Correct Answer: A. Current interna onal normalized ra o (INR).
Cogni ve Level: Applying
Client Needs Category: Reduc on of Risk Poten al
Main Lesson / Takeaway: An coagulant use requires immediate coagula on assessment
because excessive an coagula on increases the risk of catastrophic intracranial
hemorrhage with thromboly c therapy.
Detailed Ra onale: The client may be within the treatment window for thromboly c
therapy, but warfarin use makes the INR cri cally important. An elevated INR can
contraindicate IV thromboly c treatment because of increased bleeding risk.
o B. Sodium abnormali es can affect neurologic status but do not determine the
immediate safety of thromboly c therapy in this scenario.
o C. Hemoglobin A1c assesses long-term glycemic control and does not determine
immediate thromboly c eligibility.
, o D. LDL is important for long-term secondary stroke preven on but does not
determine immediate eligibility for thrombolysis.
Ques on 3: Heart Failure — Acute Pulmonary Edema
Clinical Scenario: A 76-year-old client with chronic systolic heart failure suddenly
develops severe dyspnea and anxiety. BP is 188/104 mmHg, HR 118/min, RR 34/min,
SpO₂ 82% on room air, and bilateral crackles extend halfway up both lung fields; the
client is coughing pink, frothy sputum.
Ques on Stem: Which interven on should the nurse implement first?
Op ons:
o A. Place the client in high-Fowler's posi on and apply oxygen.
o B. Administer the scheduled oral beta blocker.
o C. Encourage oral fluids to thin respiratory secre ons.
o D. Obtain the client's daily morning weight.
Answer and Ra onale
Correct Answer: A. Place the client in high-Fowler's posi on and apply oxygen.
Cogni ve Level: Analyzing
Client Needs Category: Physiological Adapta on
Main Lesson / Takeaway: Acute pulmonary edema requires immediate improvement of
ven la on and oxygena on while reducing venous return and preparing for defini ve
treatment.
Detailed Ra onale: The findings indicate acute pulmonary edema with severe
hypoxemia. High-Fowler's posi oning improves lung expansion and decreases venous
return, while oxygen supports ssue oxygena on.
o B. A scheduled beta blocker is not the immediate priority during severe acute
decompensa on and respiratory compromise.
o C. Addi onal fluid can worsen pulmonary conges on.
o D. Daily weight is valuable for monitoring heart failure but is irrelevant during an
acute respiratory emergency.
, Ques on 4: COPD Exacerba on — Oxygen Therapy
Clinical Scenario: A 65-year-old client with severe COPD presents with worsening
dyspnea and produc ve cough. The client is using accessory muscles, RR is 30/min, SpO₂
is 84% on room air, and ABG results are pH 7.31, PaCO₂ 58 mmHg, and PaO₂ 52 mmHg.
Ques on Stem: Which interven on is the priority?
Op ons:
o A. Withhold oxygen because the client has chronic CO₂ reten on.
o B. Administer controlled supplemental oxygen and trate to the prescribed
target.
o C. Encourage the client to breathe rapidly to eliminate carbon dioxide.
o D. Place the client flat to improve diaphragma c excursion.
Answer and Ra onale
Correct Answer: B. Administer controlled supplemental oxygen and trate to the
prescribed target.
Cogni ve Level: Applying
Client Needs Category: Physiological Adapta on
Main Lesson / Takeaway: Hypoxemia in COPD must be treated with carefully trated
oxygen rather than withholding oxygen because of concern about hypercapnia.
Detailed Ra onale: The client has significant hypoxemia and respiratory acidosis.
Controlled oxygen therapy is indicated, commonly targe ng an individualized satura on
range such as 88–92% in clients at risk for hypercapnic respiratory failure.
o A. Withholding oxygen exposes the client to dangerous hypoxemia.
o C. Deliberately increasing respiratory rate can increase fa gue and does not
reliably correct the underlying respiratory failure.
o D. Supine posi oning generally worsens ven la on in a severely dyspneic client.
Ques on 5: Acute Kidney Injury — Hyperkalemia
Ques on 1: Acute Coronary Syndrome — Priority Interven on
Clinical Scenario: A 68-year-old client with a history of hypertension and hyperlipidemia
reports crushing substernal chest pain radia ng to the le arm for 30 minutes. BP is
156/92 mmHg, HR 104/min, RR 22/min, SpO₂ 91% on room air, and ECG shows ST-
segment eleva on in leads II, III, and aVF. The client is diaphore c and nauseated.
Ques on Stem: Which ac on should the nurse take first?
Op ons:
o A. Administer prescribed sublingual nitroglycerin.
o B. Apply supplemental oxygen.
o C. Obtain a 12-lead ECG and no fy the provider.
o D. Administer prescribed IV morphine.
Answer and Ra onale
Correct Answer: B. Apply supplemental oxygen.
Cogni ve Level: Analyzing
Client Needs Category: Physiological Adapta on
Main Lesson / Takeaway: In acute coronary syndrome, immediate correc on of clinically
significant hypoxemia takes priority while defini ve reperfusion therapy is arranged.
Detailed Ra onale: The client has acute myocardial infarc on findings with an SpO₂ of
91% and respiratory distress, making oxygena on an immediate priority under the ABC
framework. Supplemental oxygen is appropriate when the client is hypoxemic;
meanwhile, the nurse should rapidly ac vate the acute coronary syndrome protocol and
prepare for reperfusion.
o A. Nitroglycerin reduces myocardial oxygen demand and may relieve ischemic
pain, but correc ng hypoxemia takes priority.
o C. A 12-lead ECG is essen al, but the scenario already provides diagnos c ECG
findings; oxygena on is the immediate concern.
, o D. Morphine may be considered for persistent severe pain but is not the first
interven on when hypoxemia is present.
Ques on 2: Acute Ischemic Stroke — Thromboly c Safety
Clinical Scenario: A 72-year-old client develops sudden right-sided weakness and
expressive aphasia while ea ng breakfast. Symptoms began 75 minutes ago, BP is
174/96 mmHg, blood glucose is 108 mg/dL, and the client takes warfarin for atrial
fibrilla on.
Ques on Stem: Which assessment finding is most important for the nurse to obtain
before thromboly c therapy is considered?
Op ons:
o A. Current interna onal normalized ra o (INR).
o B. Serum sodium concentra on.
o C. Hemoglobin A1c level.
o D. Current LDL cholesterol level.
Answer and Ra onale
Correct Answer: A. Current interna onal normalized ra o (INR).
Cogni ve Level: Applying
Client Needs Category: Reduc on of Risk Poten al
Main Lesson / Takeaway: An coagulant use requires immediate coagula on assessment
because excessive an coagula on increases the risk of catastrophic intracranial
hemorrhage with thromboly c therapy.
Detailed Ra onale: The client may be within the treatment window for thromboly c
therapy, but warfarin use makes the INR cri cally important. An elevated INR can
contraindicate IV thromboly c treatment because of increased bleeding risk.
o B. Sodium abnormali es can affect neurologic status but do not determine the
immediate safety of thromboly c therapy in this scenario.
o C. Hemoglobin A1c assesses long-term glycemic control and does not determine
immediate thromboly c eligibility.
, o D. LDL is important for long-term secondary stroke preven on but does not
determine immediate eligibility for thrombolysis.
Ques on 3: Heart Failure — Acute Pulmonary Edema
Clinical Scenario: A 76-year-old client with chronic systolic heart failure suddenly
develops severe dyspnea and anxiety. BP is 188/104 mmHg, HR 118/min, RR 34/min,
SpO₂ 82% on room air, and bilateral crackles extend halfway up both lung fields; the
client is coughing pink, frothy sputum.
Ques on Stem: Which interven on should the nurse implement first?
Op ons:
o A. Place the client in high-Fowler's posi on and apply oxygen.
o B. Administer the scheduled oral beta blocker.
o C. Encourage oral fluids to thin respiratory secre ons.
o D. Obtain the client's daily morning weight.
Answer and Ra onale
Correct Answer: A. Place the client in high-Fowler's posi on and apply oxygen.
Cogni ve Level: Analyzing
Client Needs Category: Physiological Adapta on
Main Lesson / Takeaway: Acute pulmonary edema requires immediate improvement of
ven la on and oxygena on while reducing venous return and preparing for defini ve
treatment.
Detailed Ra onale: The findings indicate acute pulmonary edema with severe
hypoxemia. High-Fowler's posi oning improves lung expansion and decreases venous
return, while oxygen supports ssue oxygena on.
o B. A scheduled beta blocker is not the immediate priority during severe acute
decompensa on and respiratory compromise.
o C. Addi onal fluid can worsen pulmonary conges on.
o D. Daily weight is valuable for monitoring heart failure but is irrelevant during an
acute respiratory emergency.
, Ques on 4: COPD Exacerba on — Oxygen Therapy
Clinical Scenario: A 65-year-old client with severe COPD presents with worsening
dyspnea and produc ve cough. The client is using accessory muscles, RR is 30/min, SpO₂
is 84% on room air, and ABG results are pH 7.31, PaCO₂ 58 mmHg, and PaO₂ 52 mmHg.
Ques on Stem: Which interven on is the priority?
Op ons:
o A. Withhold oxygen because the client has chronic CO₂ reten on.
o B. Administer controlled supplemental oxygen and trate to the prescribed
target.
o C. Encourage the client to breathe rapidly to eliminate carbon dioxide.
o D. Place the client flat to improve diaphragma c excursion.
Answer and Ra onale
Correct Answer: B. Administer controlled supplemental oxygen and trate to the
prescribed target.
Cogni ve Level: Applying
Client Needs Category: Physiological Adapta on
Main Lesson / Takeaway: Hypoxemia in COPD must be treated with carefully trated
oxygen rather than withholding oxygen because of concern about hypercapnia.
Detailed Ra onale: The client has significant hypoxemia and respiratory acidosis.
Controlled oxygen therapy is indicated, commonly targe ng an individualized satura on
range such as 88–92% in clients at risk for hypercapnic respiratory failure.
o A. Withholding oxygen exposes the client to dangerous hypoxemia.
o C. Deliberately increasing respiratory rate can increase fa gue and does not
reliably correct the underlying respiratory failure.
o D. Supine posi oning generally worsens ven la on in a severely dyspneic client.
Ques on 5: Acute Kidney Injury — Hyperkalemia
