PART 0: THE TABLE OF CONTENTS
• Part I: The Preview
– The Critical Axioms Cheat Sheet
• Part II: The Elite Test Bank
– Tier 1: Foundational Syntax & Application (Questions 1–18) — Cardiac, respiratory,
endocrine, hematologic, gastrointestinal, neurologic, safety and delegation
– Tier 2: Complex Application & Simulation (Questions 19–37) — Fluids and burns,
endocrine emergencies, renal, musculoskeletal, shock, anaphylaxis, perioperative care, pain
management
– Tier 3: Grandmaster Synthesis (Questions 38–55) — Multi-system crises, oncologic
emergencies, neurologic emergencies, prioritization, legal and ethical judgment
PART I: THE PREVIEW
Mastering this test bank trains the clinical judgment that separates a task-completer from a nurse
who recognizes deterioration early and acts in the correct order. Every question rewards the same
professional habit: identify the physiologic problem, protect the airway and circulation, and choose
the single safest action.
The Critical Axioms Cheat Sheet
• Airway, Breathing, Circulation First: When two actions are both correct, the one that protects
oxygenation and perfusion comes before the one that treats a lab value or a symptom.
• Treat the Patient, Then the Number: Hyperkalemia with ECG changes receives calcium first;
potassium below 3.3 mEq/L in DKA delays insulin; a therapeutic INR range is a target, not a reason
to ignore bleeding.
• Recognize the Trap Pairs: Heparin is reversed by protamine and warfarin by vitamin K; COPD
oxygen targets are 88–92%; DKA and SIADH are managed with opposite fluid strategies; nitrates
are contraindicated with phosphodiesterase inhibitors and in right ventricular infarction.
• Delegate the Task, Never the Judgment: Assessment, evaluation, teaching, and interpretation
of unstable findings stay with the RN; stable, routine, predictable tasks may go to licensed
practical nurses and unlicensed assistive personnel.
• The Unstable Patient Goes First: Sudden change, new neurologic deficit, expanding
hematoma, and airway compromise outrank chronic and expected findings in every prioritization
question.
Elite Test Bank: Medical-Surgical Nursing | Page 1
,PART II: THE ELITE TEST BANK
Tier 1: Foundational Syntax & Application (Questions 1–18)
Q1: A patient with heart failure with reduced ejection fraction receives digoxin and furosemide daily.
Before the morning medications, the nurse finds an apical heart rate of 58 beats/min and a serum
potassium of 3.0 mEq/L. Based on the principles of cardiac glycoside safety, which action is the
MOST APPROPRIATE?
A) Administer the digoxin as scheduled and ask the provider for an oral potassium order
afterward.
B) Hold the digoxin and notify the provider of the heart rate and the potassium level.
C) Administer both medications and recheck the potassium level in 24 hours.
D) Hold only the furosemide and give the digoxin because the heart rate is above 50 beats/min.
• Answer: B (Hold the digoxin and notify the provider of the heart rate and the potassium level.)
• Distractor Analysis:
– A is incorrect: Giving the drug first exposes a bradycardic, hypokalemic patient to digoxin
toxicity; the order of the actions reverses the safety sequence.
– C is incorrect: Waiting 24 hours ignores that hypokalemia increases myocardial sensitivity to
digoxin and can trigger life-threatening dysrhythmias.
– D is incorrect: The threshold of 50 beats/min is a legacy habit; the adult hold parameter is
generally below 60, and holding the diuretic does not correct the potassium already low.
The Mentor's Analysis:
Hypokalemia potentiates digoxin, so a low potassium plus a slow pulse is a toxicity warning, not a routine
dose. When facing a glycoside dose with abnormal data, the immediate priority is to withhold the drug
and report. By utilizing the hold parameters, you bypass the common trap of giving a scheduled
medication simply because it is scheduled.
Professional Intuition: Low potassium plus digoxin equals hold and call.
Q2: A patient with chronic obstructive pulmonary disease is admitted with an exacerbation. Arterial
blood gases show a chronically elevated PaCO2, and the pulse oximeter reads 84% on room air.
Based on the principles of oxygen therapy in COPD, which oxygen saturation target is the MOST
APPROPRIATE?
A) 95% to 100%, to prevent any tissue hypoxia.
B) No supplemental oxygen until a repeat arterial blood gas is obtained.
C) 88% to 92%, delivered with a controlled-flow device.
D) 92% to 96%, delivered with a non-rebreather mask.
• Answer: C (88% to 92%, delivered with a controlled-flow device.)
• Distractor Analysis:
– A is incorrect: Chasing near-normal saturations in a chronic CO2 retainer can worsen
hypercapnia through ventilation-perfusion mismatch and the Haldane effect.
– B is incorrect: Withholding oxygen from a patient at 84% risks organ hypoxia; the fear of CO2
retention calls for titration, not withdrawal.
Elite Test Bank: Medical-Surgical Nursing | Page 2
, – D is incorrect: A non-rebreather delivers high, uncontrolled concentrations, and the target
range is also too high for this patient.
The Mentor's Analysis:
The goal in chronic CO2 retention is adequate, not maximal, oxygenation. When facing a hypoxic COPD
patient, the immediate priority is to titrate oxygen to 88–92% with a precise delivery device. By utilizing a
target range, you bypass the common trap of choosing between "all the oxygen" and "none."
Professional Intuition: In COPD, aim for 88 to 92, not 100.
Q3: A patient in diabetic ketoacidosis has a glucose of 640 mg/dL, a pH of 7.18, and a serum
potassium of 3.2 mEq/L. An insulin infusion is ordered. Based on the principles of DKA management,
which action should the nurse take FIRST?
A) Hold the insulin infusion, notify the provider, and anticipate intravenous potassium
replacement.
B) Start the insulin infusion immediately because the acidosis is life-threatening.
C) Start the insulin infusion and add potassium only after the glucose falls below 250 mg/dL.
D) Give sodium bicarbonate to raise the pH before starting insulin.
• Answer: A (Hold the insulin infusion, notify the provider, and anticipate intravenous potassium
replacement.)
• Distractor Analysis:
– B is incorrect: Insulin drives potassium into cells; at a level of 3.2 mEq/L it can precipitate
dysrhythmia or respiratory muscle weakness.
– C is incorrect: Delaying potassium until the glucose falls fails to protect the heart during the
period of greatest risk.
– D is incorrect: Bicarbonate is reserved for severe acidosis (commonly pH below 6.9) and can
worsen hypokalemia.
The Mentor's Analysis:
Total body potassium is depleted in DKA even when the serum value looks normal, and insulin will lower it
further. When facing a potassium below 3.3 mEq/L, the immediate priority is to replace potassium before
insulin. By utilizing this sequencing, you bypass the common trap of treating the glucose first.
Professional Intuition: Potassium under 3.3 means replace first, insulin second.
Q4: A patient presents with acute ischemic stroke 5 hours after symptom onset and is not a
candidate for thrombolytic therapy. The blood pressure is 190/102 mm Hg. Based on the principles of
acute stroke care, which action should the nurse anticipate?
A) Administer IV labetalol to reduce the pressure to 140/90 mm Hg within one hour.
B) Start a nitroprusside infusion to lower the mean arterial pressure by 50%.
C) Give sublingual nifedipine to prevent hemorrhagic transformation.
D) Withhold antihypertensive treatment unless the pressure exceeds approximately 220/120 mm
Hg.
• Answer: D (Withhold antihypertensive treatment unless the pressure exceeds approximately
220/120 mm Hg.)
• Distractor Analysis:
Elite Test Bank: Medical-Surgical Nursing | Page 3
, – A is incorrect: Aggressive lowering reduces perfusion to the ischemic penumbra and can
enlarge the infarct.
– B is incorrect: A 50% reduction is dangerous; even when treatment is indicated, reduction is
cautious and graded.
– C is incorrect: Rapid-acting sublingual calcium channel blockers cause unpredictable
precipitous drops and are not used.
The Mentor's Analysis:
After an ischemic stroke, the brain depends on elevated pressure to perfuse tissue around the infarct.
When facing a hypertensive stroke patient without thrombolysis, the immediate priority is permissive
hypertension. By utilizing the 220/120 threshold, you bypass the common trap of normalizing a pressure
the brain needs.
Professional Intuition: In an untreated ischemic stroke, let the pressure ride.
Q5: A patient with chest pain has ST elevation in leads II, III, and aVF. The blood pressure is 88/54
mm Hg, and a right-sided ECG shows ST elevation in V4R. Based on the principles of inferior
myocardial infarction with right ventricular involvement, which order should the nurse QUESTION?
A) Aspirin 324 mg to be chewed.
B) Nitroglycerin 0.4 mg sublingual.
C) A 500 mL intravenous bolus of 0.9% sodium chloride.
D) Continuous cardiac monitoring.
• Answer: B (Nitroglycerin 0.4 mg sublingual.)
• Distractor Analysis:
– A is incorrect: Aspirin is indicated for acute coronary syndrome and is not contraindicated
here.
– C is incorrect: A fluid bolus supports the preload-dependent right ventricle and is an expected
therapy.
– D is incorrect: Monitoring is essential because inferior infarction commonly causes bradycardia
and heart block.
The Mentor's Analysis:
The infarcted right ventricle depends on preload to push blood to the left side, and nitrates are
venodilators that remove that preload. When facing an inferior infarction with hypotension, the
immediate priority is to protect preload. By utilizing a right-sided ECG, you bypass the common trap of
giving nitroglycerin by reflex.
Professional Intuition: Inferior MI with a hypotensive patient: fluids yes, nitrates no.
Q6: Fifteen minutes into a transfusion of packed red blood cells, a patient reports chills and flank
pain, and the temperature rises from 98.6°F to 101.4°F (38.6°C). Based on the principles of
transfusion safety, which action is the FIRST priority?
A) Stop the transfusion and infuse 0.9% sodium chloride through new tubing.
B) Slow the transfusion rate, give acetaminophen, and reassess in 15 minutes.
C) Notify the blood bank and then continue the transfusion until they respond.
D) Flush the existing tubing with saline and resume the unit at a slower rate.
Elite Test Bank: Medical-Surgical Nursing | Page 4
• Part I: The Preview
– The Critical Axioms Cheat Sheet
• Part II: The Elite Test Bank
– Tier 1: Foundational Syntax & Application (Questions 1–18) — Cardiac, respiratory,
endocrine, hematologic, gastrointestinal, neurologic, safety and delegation
– Tier 2: Complex Application & Simulation (Questions 19–37) — Fluids and burns,
endocrine emergencies, renal, musculoskeletal, shock, anaphylaxis, perioperative care, pain
management
– Tier 3: Grandmaster Synthesis (Questions 38–55) — Multi-system crises, oncologic
emergencies, neurologic emergencies, prioritization, legal and ethical judgment
PART I: THE PREVIEW
Mastering this test bank trains the clinical judgment that separates a task-completer from a nurse
who recognizes deterioration early and acts in the correct order. Every question rewards the same
professional habit: identify the physiologic problem, protect the airway and circulation, and choose
the single safest action.
The Critical Axioms Cheat Sheet
• Airway, Breathing, Circulation First: When two actions are both correct, the one that protects
oxygenation and perfusion comes before the one that treats a lab value or a symptom.
• Treat the Patient, Then the Number: Hyperkalemia with ECG changes receives calcium first;
potassium below 3.3 mEq/L in DKA delays insulin; a therapeutic INR range is a target, not a reason
to ignore bleeding.
• Recognize the Trap Pairs: Heparin is reversed by protamine and warfarin by vitamin K; COPD
oxygen targets are 88–92%; DKA and SIADH are managed with opposite fluid strategies; nitrates
are contraindicated with phosphodiesterase inhibitors and in right ventricular infarction.
• Delegate the Task, Never the Judgment: Assessment, evaluation, teaching, and interpretation
of unstable findings stay with the RN; stable, routine, predictable tasks may go to licensed
practical nurses and unlicensed assistive personnel.
• The Unstable Patient Goes First: Sudden change, new neurologic deficit, expanding
hematoma, and airway compromise outrank chronic and expected findings in every prioritization
question.
Elite Test Bank: Medical-Surgical Nursing | Page 1
,PART II: THE ELITE TEST BANK
Tier 1: Foundational Syntax & Application (Questions 1–18)
Q1: A patient with heart failure with reduced ejection fraction receives digoxin and furosemide daily.
Before the morning medications, the nurse finds an apical heart rate of 58 beats/min and a serum
potassium of 3.0 mEq/L. Based on the principles of cardiac glycoside safety, which action is the
MOST APPROPRIATE?
A) Administer the digoxin as scheduled and ask the provider for an oral potassium order
afterward.
B) Hold the digoxin and notify the provider of the heart rate and the potassium level.
C) Administer both medications and recheck the potassium level in 24 hours.
D) Hold only the furosemide and give the digoxin because the heart rate is above 50 beats/min.
• Answer: B (Hold the digoxin and notify the provider of the heart rate and the potassium level.)
• Distractor Analysis:
– A is incorrect: Giving the drug first exposes a bradycardic, hypokalemic patient to digoxin
toxicity; the order of the actions reverses the safety sequence.
– C is incorrect: Waiting 24 hours ignores that hypokalemia increases myocardial sensitivity to
digoxin and can trigger life-threatening dysrhythmias.
– D is incorrect: The threshold of 50 beats/min is a legacy habit; the adult hold parameter is
generally below 60, and holding the diuretic does not correct the potassium already low.
The Mentor's Analysis:
Hypokalemia potentiates digoxin, so a low potassium plus a slow pulse is a toxicity warning, not a routine
dose. When facing a glycoside dose with abnormal data, the immediate priority is to withhold the drug
and report. By utilizing the hold parameters, you bypass the common trap of giving a scheduled
medication simply because it is scheduled.
Professional Intuition: Low potassium plus digoxin equals hold and call.
Q2: A patient with chronic obstructive pulmonary disease is admitted with an exacerbation. Arterial
blood gases show a chronically elevated PaCO2, and the pulse oximeter reads 84% on room air.
Based on the principles of oxygen therapy in COPD, which oxygen saturation target is the MOST
APPROPRIATE?
A) 95% to 100%, to prevent any tissue hypoxia.
B) No supplemental oxygen until a repeat arterial blood gas is obtained.
C) 88% to 92%, delivered with a controlled-flow device.
D) 92% to 96%, delivered with a non-rebreather mask.
• Answer: C (88% to 92%, delivered with a controlled-flow device.)
• Distractor Analysis:
– A is incorrect: Chasing near-normal saturations in a chronic CO2 retainer can worsen
hypercapnia through ventilation-perfusion mismatch and the Haldane effect.
– B is incorrect: Withholding oxygen from a patient at 84% risks organ hypoxia; the fear of CO2
retention calls for titration, not withdrawal.
Elite Test Bank: Medical-Surgical Nursing | Page 2
, – D is incorrect: A non-rebreather delivers high, uncontrolled concentrations, and the target
range is also too high for this patient.
The Mentor's Analysis:
The goal in chronic CO2 retention is adequate, not maximal, oxygenation. When facing a hypoxic COPD
patient, the immediate priority is to titrate oxygen to 88–92% with a precise delivery device. By utilizing a
target range, you bypass the common trap of choosing between "all the oxygen" and "none."
Professional Intuition: In COPD, aim for 88 to 92, not 100.
Q3: A patient in diabetic ketoacidosis has a glucose of 640 mg/dL, a pH of 7.18, and a serum
potassium of 3.2 mEq/L. An insulin infusion is ordered. Based on the principles of DKA management,
which action should the nurse take FIRST?
A) Hold the insulin infusion, notify the provider, and anticipate intravenous potassium
replacement.
B) Start the insulin infusion immediately because the acidosis is life-threatening.
C) Start the insulin infusion and add potassium only after the glucose falls below 250 mg/dL.
D) Give sodium bicarbonate to raise the pH before starting insulin.
• Answer: A (Hold the insulin infusion, notify the provider, and anticipate intravenous potassium
replacement.)
• Distractor Analysis:
– B is incorrect: Insulin drives potassium into cells; at a level of 3.2 mEq/L it can precipitate
dysrhythmia or respiratory muscle weakness.
– C is incorrect: Delaying potassium until the glucose falls fails to protect the heart during the
period of greatest risk.
– D is incorrect: Bicarbonate is reserved for severe acidosis (commonly pH below 6.9) and can
worsen hypokalemia.
The Mentor's Analysis:
Total body potassium is depleted in DKA even when the serum value looks normal, and insulin will lower it
further. When facing a potassium below 3.3 mEq/L, the immediate priority is to replace potassium before
insulin. By utilizing this sequencing, you bypass the common trap of treating the glucose first.
Professional Intuition: Potassium under 3.3 means replace first, insulin second.
Q4: A patient presents with acute ischemic stroke 5 hours after symptom onset and is not a
candidate for thrombolytic therapy. The blood pressure is 190/102 mm Hg. Based on the principles of
acute stroke care, which action should the nurse anticipate?
A) Administer IV labetalol to reduce the pressure to 140/90 mm Hg within one hour.
B) Start a nitroprusside infusion to lower the mean arterial pressure by 50%.
C) Give sublingual nifedipine to prevent hemorrhagic transformation.
D) Withhold antihypertensive treatment unless the pressure exceeds approximately 220/120 mm
Hg.
• Answer: D (Withhold antihypertensive treatment unless the pressure exceeds approximately
220/120 mm Hg.)
• Distractor Analysis:
Elite Test Bank: Medical-Surgical Nursing | Page 3
, – A is incorrect: Aggressive lowering reduces perfusion to the ischemic penumbra and can
enlarge the infarct.
– B is incorrect: A 50% reduction is dangerous; even when treatment is indicated, reduction is
cautious and graded.
– C is incorrect: Rapid-acting sublingual calcium channel blockers cause unpredictable
precipitous drops and are not used.
The Mentor's Analysis:
After an ischemic stroke, the brain depends on elevated pressure to perfuse tissue around the infarct.
When facing a hypertensive stroke patient without thrombolysis, the immediate priority is permissive
hypertension. By utilizing the 220/120 threshold, you bypass the common trap of normalizing a pressure
the brain needs.
Professional Intuition: In an untreated ischemic stroke, let the pressure ride.
Q5: A patient with chest pain has ST elevation in leads II, III, and aVF. The blood pressure is 88/54
mm Hg, and a right-sided ECG shows ST elevation in V4R. Based on the principles of inferior
myocardial infarction with right ventricular involvement, which order should the nurse QUESTION?
A) Aspirin 324 mg to be chewed.
B) Nitroglycerin 0.4 mg sublingual.
C) A 500 mL intravenous bolus of 0.9% sodium chloride.
D) Continuous cardiac monitoring.
• Answer: B (Nitroglycerin 0.4 mg sublingual.)
• Distractor Analysis:
– A is incorrect: Aspirin is indicated for acute coronary syndrome and is not contraindicated
here.
– C is incorrect: A fluid bolus supports the preload-dependent right ventricle and is an expected
therapy.
– D is incorrect: Monitoring is essential because inferior infarction commonly causes bradycardia
and heart block.
The Mentor's Analysis:
The infarcted right ventricle depends on preload to push blood to the left side, and nitrates are
venodilators that remove that preload. When facing an inferior infarction with hypotension, the
immediate priority is to protect preload. By utilizing a right-sided ECG, you bypass the common trap of
giving nitroglycerin by reflex.
Professional Intuition: Inferior MI with a hypotensive patient: fluids yes, nitrates no.
Q6: Fifteen minutes into a transfusion of packed red blood cells, a patient reports chills and flank
pain, and the temperature rises from 98.6°F to 101.4°F (38.6°C). Based on the principles of
transfusion safety, which action is the FIRST priority?
A) Stop the transfusion and infuse 0.9% sodium chloride through new tubing.
B) Slow the transfusion rate, give acetaminophen, and reassess in 15 minutes.
C) Notify the blood bank and then continue the transfusion until they respond.
D) Flush the existing tubing with saline and resume the unit at a slower rate.
Elite Test Bank: Medical-Surgical Nursing | Page 4
