ANCC Medical-Surgical Nursing Certification Examination (MEDSURG-BC™)
Advanced Clinical Judgment Question Bank V2.0
150 High-Complexity Multiple-Choice Questions for Experienced Medical-Surgical Nurses
TABLE OF CONTENTS
Section Topic Area Questions
Cardiovascular System – Advanced Hemodynamics &
I 1–18
Complex Arrhythmias
Respiratory System – Critical Care & Ventilator
II 19–33
Management
Gastrointestinal System – Complex Surgical & Hepatic
III 34–48
Disorders
Renal and Genitourinary System – Acute Kidney Injury
IV 49–61
& Fluid Management
Endocrine and Metabolic Disorders – Critical
V 62–76
Endocrine Emergencies
Neurological and Sensorineural System – Stroke,
VI 77–90
Seizures & Neurocritical Care
Musculoskeletal and Integumentary System – Trauma,
VII 91–103
Wound & Burn Management
Immunologic and Hematologic Systems – Transfusion
VIII 104–115
Medicine & Immunodeficiency
IX Multisystem Disorders, Shock States & Critical Care 116–129
Professional Role, Ethics, Leadership & Quality
X 130–150
Improvement
SECTION I: CARDIOVASCULAR SYSTEM – ADVANCED HEMODYNAMICS & COMPLEX
ARRHYTHMIAS
(Questions 1–18)
🟢 1. A 74-year-old male with a history of ischemic cardiomyopathy (EF 25%) is admitted with acute decompensated heart failure. He is receiving
continuous infusion of dobutamine at 5 mcg/kg/min and milrinone at 0.5 mcg/kg/min. His vital signs: HR 118, BP 88/52, RR 24, SpO₂ 91% on 4L nasal
cannula. Which assessment finding would indicate the HIGHEST priority for intervention?
A. Heart rate of 118 beats/min
B. Blood pressure of 88/52 mmHg
C. 🔴🔴 New-onset atrial fibrillation with rapid ventricular response
D. SpO₂ of 91% on 4L nasal cannula
,Rationale: New-onset atrial fibrillation with RVR in a patient with severe heart failure and cardiogenic shock is a life-threatening arrhythmia that can
precipitate further hemodynamic collapse. It requires immediate intervention including rate control and possible cardioversion. While the tachycardia,
hypotension, and hypoxia are concerning, they are expected findings in this clinical context. The new arrhythmia represents an acute deterioration
requiring emergent action.
🟢 2. A patient with a St. Jude Medical mechanical aortic valve is on warfarin therapy. The INR is 1.8. The patient is scheduled for a dental extraction in 3
days. Which action should the nurse anticipate?
A. Administer vitamin K 10 mg IV push
B. Hold warfarin for 5 days and bridge with enoxaparin
C. 🔴🔴 Continue warfarin and plan for periprocedural bridging with heparin
D. Increase warfarin dose to achieve INR 3.5 before procedure
Rationale: Patients with mechanical heart valves require therapeutic anticoagulation. For a procedure, periprocedural bridging with unfractionated heparin
or low-molecular-weight heparin is typically planned while warfarin is held. The INR of 1.8 is subtherapeutic and requires correction before bridging.
Vitamin K would reverse anticoagulation and increase thrombotic risk. Increasing the dose immediately before surgery is not appropriate.
🟢 3. A patient with an acute anterior STEMI undergoes successful PCI with drug-eluting stent placement to the LAD. Which medication regimen is MOST
appropriate for preventing stent thrombosis?
A. Aspirin 81 mg daily only
B. 🔴🔴 Aspirin 81 mg daily + ticagrelor 90 mg twice daily
C. Aspirin 325 mg daily + warfarin
D. Clopidogrel 75 mg daily only
Rationale: Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor (ticagrelor, prasugrel, or clopidogrel) is the standard of care following DES
placement to prevent stent thrombosis. Ticagrelor is preferred over clopidogrel in many cases due to faster onset and more consistent platelet inhibition.
Warfarin is not indicated for stent thrombosis prevention.
🟢 4. A patient is in sustained monomorphic ventricular tachycardia at 180 beats/min with a palpable pulse. The patient is hemodynamically stable but
symptomatic with chest discomfort. Which intervention should the nurse anticipate?
A. Immediate synchronized cardioversion
B. 🔴🔴 Amiodarone 150 mg IV bolus over 10 minutes
C. Immediate defibrillation
D. Adenosine 6 mg IV push
Rationale: In stable monomorphic VT with a pulse, pharmacologic therapy with amiodarone or lidocaine is the first-line treatment. Synchronized
cardioversion is indicated if the patient becomes hemodynamically unstable. Defibrillation is for pulseless VT. Adenosine is not effective for VT.
🟢 5. A patient with chronic heart failure on sacubitril/valsartan (Entresto) presents with angioedema involving the tongue and lips. Which action should
the nurse take FIRST?
A. 🔴🔴 Discontinue sacubitril/valsartan and administer epinephrine
B. Administer diphenhydramine 50 mg IV
C. Continue the medication and monitor closely
D. Administer methylprednisolone 125 mg IV
Rationale: Angioedema is a life-threatening adverse reaction to sacubitril/valsartan (an ARNI). The medication must be immediately discontinued, and
epinephrine should be administered for airway protection. Antihistamines and corticosteroids are adjunctive therapies but not first-line for acute
angioedema.
🟢 6. A patient's telemetry monitor shows a regular rhythm with a rate of 38 beats/min, narrow QRS complexes, and inverted P waves preceding each QRS
with a PR interval of 0.10 seconds. The nurse should interpret this rhythm as:
A. Sinus bradycardia
B. 🔴🔴 Junctional bradycardia
C. First-degree AV block
D. Accelerated idioventricular rhythm
, Rationale: Junctional bradycardia is characterized by a rate <40 bpm, narrow QRS complexes, and inverted or absent P waves with a short PR interval
(<0.12 seconds) because the impulse originates near the AV node. Sinus bradycardia would have normal upright P waves.
🟢 7. A patient with a permanent pacemaker has a pacing rate of 70 beats/min. The ECG shows pacing spikes that occur at irregular intervals, some of
which are not followed by QRS complexes. The nurse should recognize this as:
A. Failure to capture
B. 🔴🔴 Failure to capture with intermittent sensing failure
C. Oversensing
D. Pacemaker syndrome
Rationale: Failure to capture occurs when pacing spikes do not result in QRS complexes. Intermittent sensing failure means the pacemaker sometimes fails
to recognize intrinsic beats, leading to asynchronous pacing. This combination suggests pacemaker malfunction requiring evaluation.
🟢 8. A patient with suspected aortic dissection presents with severe ripping chest pain radiating to the back, blood pressure 180/100 mmHg, and unequal
radial pulses. Which medication should the nurse anticipate administering FIRST?
A. 🔴🔴 IV esmolol or labetalol to reduce heart rate and blood pressure
B. IV nitroglycerin to reduce preload
C. IV morphine for pain
D. IV heparin to prevent thrombosis
Rationale: The priority in aortic dissection is to reduce the force of left ventricular ejection (dP/dt) by decreasing heart rate and blood pressure. Beta-
blockers (esmolol, labetalol) are the first-line agents. Nitroglycerin alone may increase shear forces. Pain control is important but secondary to
hemodynamic management.
🟢 9. A patient with a history of heart failure with preserved ejection fraction (HFpEF) presents with acute dyspnea and pulmonary edema. The patient's BP
is 165/95 mmHg. Which medication is MOST appropriate for acute management?
A. Dobutamine infusion
B. 🔴🔴 IV nitroglycerin and IV furosemide
C. IV milrinone
D. IV dopamine
Rationale: HFpEF is characterized by diastolic dysfunction and hypertension. The acute management focuses on reducing preload (nitroglycerin) and
volume overload (furosemide). Inotropes like dobutamine and milrinone are generally not indicated in HFpEF and may worsen the condition.
🟢 10. A patient develops a new left bundle branch block (LBBB) following a percutaneous coronary intervention. Which finding would be MOST
concerning?
A. The LBBB is asymptomatic
B. 🔴🔴 The LBBB is associated with chest pain and hemodynamic instability
C. The LBBB resolves spontaneously
D. The LBBB is present on prior ECGs
Rationale: New-onset LBBB in the setting of PCI may indicate myocardial ischemia or injury. If associated with chest pain or hemodynamic instability, it
suggests ongoing ischemia requiring immediate evaluation. Asymptomatic or resolving LBBB is less concerning.
🟢 11. A patient with pericarditis is experiencing severe pain. Which position provides the MOST relief?
A. Supine with head flat
B. 🔴🔴 Sitting upright and leaning forward
C. Left lateral decubitus position
D. Prone position
Rationale: Pericarditis pain is typically relieved by sitting upright and leaning forward, which reduces pressure on the pericardium. Pain worsens when lying
flat due to increased pericardial irritation.
Advanced Clinical Judgment Question Bank V2.0
150 High-Complexity Multiple-Choice Questions for Experienced Medical-Surgical Nurses
TABLE OF CONTENTS
Section Topic Area Questions
Cardiovascular System – Advanced Hemodynamics &
I 1–18
Complex Arrhythmias
Respiratory System – Critical Care & Ventilator
II 19–33
Management
Gastrointestinal System – Complex Surgical & Hepatic
III 34–48
Disorders
Renal and Genitourinary System – Acute Kidney Injury
IV 49–61
& Fluid Management
Endocrine and Metabolic Disorders – Critical
V 62–76
Endocrine Emergencies
Neurological and Sensorineural System – Stroke,
VI 77–90
Seizures & Neurocritical Care
Musculoskeletal and Integumentary System – Trauma,
VII 91–103
Wound & Burn Management
Immunologic and Hematologic Systems – Transfusion
VIII 104–115
Medicine & Immunodeficiency
IX Multisystem Disorders, Shock States & Critical Care 116–129
Professional Role, Ethics, Leadership & Quality
X 130–150
Improvement
SECTION I: CARDIOVASCULAR SYSTEM – ADVANCED HEMODYNAMICS & COMPLEX
ARRHYTHMIAS
(Questions 1–18)
🟢 1. A 74-year-old male with a history of ischemic cardiomyopathy (EF 25%) is admitted with acute decompensated heart failure. He is receiving
continuous infusion of dobutamine at 5 mcg/kg/min and milrinone at 0.5 mcg/kg/min. His vital signs: HR 118, BP 88/52, RR 24, SpO₂ 91% on 4L nasal
cannula. Which assessment finding would indicate the HIGHEST priority for intervention?
A. Heart rate of 118 beats/min
B. Blood pressure of 88/52 mmHg
C. 🔴🔴 New-onset atrial fibrillation with rapid ventricular response
D. SpO₂ of 91% on 4L nasal cannula
,Rationale: New-onset atrial fibrillation with RVR in a patient with severe heart failure and cardiogenic shock is a life-threatening arrhythmia that can
precipitate further hemodynamic collapse. It requires immediate intervention including rate control and possible cardioversion. While the tachycardia,
hypotension, and hypoxia are concerning, they are expected findings in this clinical context. The new arrhythmia represents an acute deterioration
requiring emergent action.
🟢 2. A patient with a St. Jude Medical mechanical aortic valve is on warfarin therapy. The INR is 1.8. The patient is scheduled for a dental extraction in 3
days. Which action should the nurse anticipate?
A. Administer vitamin K 10 mg IV push
B. Hold warfarin for 5 days and bridge with enoxaparin
C. 🔴🔴 Continue warfarin and plan for periprocedural bridging with heparin
D. Increase warfarin dose to achieve INR 3.5 before procedure
Rationale: Patients with mechanical heart valves require therapeutic anticoagulation. For a procedure, periprocedural bridging with unfractionated heparin
or low-molecular-weight heparin is typically planned while warfarin is held. The INR of 1.8 is subtherapeutic and requires correction before bridging.
Vitamin K would reverse anticoagulation and increase thrombotic risk. Increasing the dose immediately before surgery is not appropriate.
🟢 3. A patient with an acute anterior STEMI undergoes successful PCI with drug-eluting stent placement to the LAD. Which medication regimen is MOST
appropriate for preventing stent thrombosis?
A. Aspirin 81 mg daily only
B. 🔴🔴 Aspirin 81 mg daily + ticagrelor 90 mg twice daily
C. Aspirin 325 mg daily + warfarin
D. Clopidogrel 75 mg daily only
Rationale: Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor (ticagrelor, prasugrel, or clopidogrel) is the standard of care following DES
placement to prevent stent thrombosis. Ticagrelor is preferred over clopidogrel in many cases due to faster onset and more consistent platelet inhibition.
Warfarin is not indicated for stent thrombosis prevention.
🟢 4. A patient is in sustained monomorphic ventricular tachycardia at 180 beats/min with a palpable pulse. The patient is hemodynamically stable but
symptomatic with chest discomfort. Which intervention should the nurse anticipate?
A. Immediate synchronized cardioversion
B. 🔴🔴 Amiodarone 150 mg IV bolus over 10 minutes
C. Immediate defibrillation
D. Adenosine 6 mg IV push
Rationale: In stable monomorphic VT with a pulse, pharmacologic therapy with amiodarone or lidocaine is the first-line treatment. Synchronized
cardioversion is indicated if the patient becomes hemodynamically unstable. Defibrillation is for pulseless VT. Adenosine is not effective for VT.
🟢 5. A patient with chronic heart failure on sacubitril/valsartan (Entresto) presents with angioedema involving the tongue and lips. Which action should
the nurse take FIRST?
A. 🔴🔴 Discontinue sacubitril/valsartan and administer epinephrine
B. Administer diphenhydramine 50 mg IV
C. Continue the medication and monitor closely
D. Administer methylprednisolone 125 mg IV
Rationale: Angioedema is a life-threatening adverse reaction to sacubitril/valsartan (an ARNI). The medication must be immediately discontinued, and
epinephrine should be administered for airway protection. Antihistamines and corticosteroids are adjunctive therapies but not first-line for acute
angioedema.
🟢 6. A patient's telemetry monitor shows a regular rhythm with a rate of 38 beats/min, narrow QRS complexes, and inverted P waves preceding each QRS
with a PR interval of 0.10 seconds. The nurse should interpret this rhythm as:
A. Sinus bradycardia
B. 🔴🔴 Junctional bradycardia
C. First-degree AV block
D. Accelerated idioventricular rhythm
, Rationale: Junctional bradycardia is characterized by a rate <40 bpm, narrow QRS complexes, and inverted or absent P waves with a short PR interval
(<0.12 seconds) because the impulse originates near the AV node. Sinus bradycardia would have normal upright P waves.
🟢 7. A patient with a permanent pacemaker has a pacing rate of 70 beats/min. The ECG shows pacing spikes that occur at irregular intervals, some of
which are not followed by QRS complexes. The nurse should recognize this as:
A. Failure to capture
B. 🔴🔴 Failure to capture with intermittent sensing failure
C. Oversensing
D. Pacemaker syndrome
Rationale: Failure to capture occurs when pacing spikes do not result in QRS complexes. Intermittent sensing failure means the pacemaker sometimes fails
to recognize intrinsic beats, leading to asynchronous pacing. This combination suggests pacemaker malfunction requiring evaluation.
🟢 8. A patient with suspected aortic dissection presents with severe ripping chest pain radiating to the back, blood pressure 180/100 mmHg, and unequal
radial pulses. Which medication should the nurse anticipate administering FIRST?
A. 🔴🔴 IV esmolol or labetalol to reduce heart rate and blood pressure
B. IV nitroglycerin to reduce preload
C. IV morphine for pain
D. IV heparin to prevent thrombosis
Rationale: The priority in aortic dissection is to reduce the force of left ventricular ejection (dP/dt) by decreasing heart rate and blood pressure. Beta-
blockers (esmolol, labetalol) are the first-line agents. Nitroglycerin alone may increase shear forces. Pain control is important but secondary to
hemodynamic management.
🟢 9. A patient with a history of heart failure with preserved ejection fraction (HFpEF) presents with acute dyspnea and pulmonary edema. The patient's BP
is 165/95 mmHg. Which medication is MOST appropriate for acute management?
A. Dobutamine infusion
B. 🔴🔴 IV nitroglycerin and IV furosemide
C. IV milrinone
D. IV dopamine
Rationale: HFpEF is characterized by diastolic dysfunction and hypertension. The acute management focuses on reducing preload (nitroglycerin) and
volume overload (furosemide). Inotropes like dobutamine and milrinone are generally not indicated in HFpEF and may worsen the condition.
🟢 10. A patient develops a new left bundle branch block (LBBB) following a percutaneous coronary intervention. Which finding would be MOST
concerning?
A. The LBBB is asymptomatic
B. 🔴🔴 The LBBB is associated with chest pain and hemodynamic instability
C. The LBBB resolves spontaneously
D. The LBBB is present on prior ECGs
Rationale: New-onset LBBB in the setting of PCI may indicate myocardial ischemia or injury. If associated with chest pain or hemodynamic instability, it
suggests ongoing ischemia requiring immediate evaluation. Asymptomatic or resolving LBBB is less concerning.
🟢 11. A patient with pericarditis is experiencing severe pain. Which position provides the MOST relief?
A. Supine with head flat
B. 🔴🔴 Sitting upright and leaning forward
C. Left lateral decubitus position
D. Prone position
Rationale: Pericarditis pain is typically relieved by sitting upright and leaning forward, which reduces pressure on the pericardium. Pain worsens when lying
flat due to increased pericardial irritation.
