Medical Surgical Nursing 2026 Clinical
Priority Practice Test Questions Detailed
Explanations Rapid Assessment Sepsis Shock
Emergencies Patient Safety Nursing Actions
SECTION 1: RAPID ASSESSMENT AND CLINICAL PRIORITIZATION
(Questions 1-25)
1. A nurse is caring for four patients on a medical-surgical unit. Which patient
should the nurse assess first?
A) A patient with COPD reporting increased shortness of breath with oxygen
saturation of 88%
B) A patient requesting pain medication for a headache rated 4/10
C) A patient scheduled for discharge teaching in 1 hour
D) A patient with a blood glucose of 180 mg/dL after breakfast
Answer: A) A patient with COPD reporting increased shortness of breath
with oxygen saturation of 88%
Rationale: Using the ABC (Airway, Breathing, Circulation) priority framework,
the patient with respiratory distress and hypoxemia (SpO2 88%) requires
immediate assessment and intervention. This patient is demonstrating signs of
inadequate oxygenation, which can rapidly progress to respiratory failure. The
other patients have less urgent needs: pain management (B), discharge teaching
(C), and an elevated but non-critical blood glucose (D).
,2. A nurse is conducting a rapid assessment on a patient who just arrived in
the emergency department. Which assessment should the nurse perform first?
A) Obtain a complete health history
B) Assess airway patency and breathing
C) Check blood pressure and heart rate
D) Perform a pain assessment
Answer: B) Assess airway patency and breathing
Rationale: The priority in any rapid assessment is to evaluate the ABCs: Airway,
Breathing, and Circulation. Airway patency is the first priority because without a
patent airway, the patient cannot breathe or oxygenate. The nurse should assess for
stridor, wheezing, or absent breath sounds. Only after ensuring the airway is patent
should the nurse proceed to breathing, circulation, and other assessments.
3. A nurse is triaging patients after a mass casualty incident. Which patient
should receive treatment first according to disaster triage principles?
A) A patient with a fractured arm and stable vital signs
B) A patient with an open abdominal wound and hypotension
C) A patient with minor lacerations and ambulatory status
D) A patient with a sprained ankle and normal vital signs
Answer: B) A patient with an open abdominal wound and hypotension
Rationale: In disaster triage, patients are categorized by acuity. The patient with
an open abdominal wound and hypotension is classified as "red" (immediate/life-
threatening) and requires immediate intervention. The patient with a fractured arm
(yellow/delayed), minor lacerations (green/minor), and sprained ankle
(green/minor) have less urgent needs. The goal is to do the greatest good for the
greatest number of patients.
4. A nurse is caring for a patient who suddenly becomes unresponsive. Which
action should the nurse take first?
,A) Call for help and check for a pulse
B) Start chest compressions immediately
C) Administer oxygen via nasal cannula
D) Obtain a blood glucose reading
Answer: A) Call for help and check for a pulse
Rationale: When a patient becomes unresponsive, the first action is to call for help
and simultaneously check for a pulse and breathing. If the patient is pulseless and
not breathing, CPR should be initiated immediately. If a pulse is present but the
patient is not breathing, rescue breaths should be provided. Calling for help ensures
additional resources are available while the nurse begins assessment.
5. A nurse is assessing a patient who is experiencing an acute change in mental
status. Which finding is most concerning?
A) Confusion that improves with orientation
B) Sudden onset of agitation and restlessness
C) Mild drowsiness after pain medication
D) Difficulty finding words occasionally
Answer: B) Sudden onset of agitation and restlessness
Rationale: Sudden onset of agitation and restlessness in a patient with an acute
change in mental status may indicate hypoxia, hypoglycemia, or increased
intracranial pressure. This is a concerning finding that requires immediate
assessment and intervention. Confusion that improves with orientation, mild
drowsiness after pain medication, and occasional word-finding difficulty are less
immediately concerning.
6. A nurse is assessing a patient's level of consciousness using the Glasgow
Coma Scale (GCS). Which finding should the nurse report immediately?
A) GCS score of 15
B) GCS score of 12
, C) GCS score of 8
D) GCS score of 10
Answer: C) GCS score of 8
Rationale: A GCS score of 8 or less indicates severe neurological impairment and
is the threshold for endotracheal intubation to protect the airway. Patients with
GCS ≤8 cannot adequately protect their airway and are at high risk for aspiration.
The nurse should prepare for intubation and mechanical ventilation. GCS scores of
12 and 10 indicate moderate impairment, while 15 is normal.
7. A nurse is assessing a patient who is experiencing chest pain. Which finding
requires immediate intervention?
A) Pain rated 4/10 that is relieved by rest
B) Pain associated with diaphoresis and nausea
C) Pain that worsens with deep breathing
D) Pain that is reproducible with palpation
Answer: B) Pain associated with diaphoresis and nausea
Rationale: Chest pain associated with diaphoresis and nausea is a classic
presentation of acute myocardial infarction and requires immediate intervention.
The nurse should obtain a 12-lead ECG, administer aspirin, and notify the
provider. Pain relieved by rest may indicate stable angina. Pain that worsens with
deep breathing may indicate pleuritic chest pain. Pain reproducible with palpation
may indicate musculoskeletal pain.
8. A nurse is assessing a patient who is postoperative day 1 following
abdominal surgery. Which finding requires immediate notification of the
provider?
A) Temperature of 99.8°F (37.7°C)
B) Heart rate of 92 beats per minute
Priority Practice Test Questions Detailed
Explanations Rapid Assessment Sepsis Shock
Emergencies Patient Safety Nursing Actions
SECTION 1: RAPID ASSESSMENT AND CLINICAL PRIORITIZATION
(Questions 1-25)
1. A nurse is caring for four patients on a medical-surgical unit. Which patient
should the nurse assess first?
A) A patient with COPD reporting increased shortness of breath with oxygen
saturation of 88%
B) A patient requesting pain medication for a headache rated 4/10
C) A patient scheduled for discharge teaching in 1 hour
D) A patient with a blood glucose of 180 mg/dL after breakfast
Answer: A) A patient with COPD reporting increased shortness of breath
with oxygen saturation of 88%
Rationale: Using the ABC (Airway, Breathing, Circulation) priority framework,
the patient with respiratory distress and hypoxemia (SpO2 88%) requires
immediate assessment and intervention. This patient is demonstrating signs of
inadequate oxygenation, which can rapidly progress to respiratory failure. The
other patients have less urgent needs: pain management (B), discharge teaching
(C), and an elevated but non-critical blood glucose (D).
,2. A nurse is conducting a rapid assessment on a patient who just arrived in
the emergency department. Which assessment should the nurse perform first?
A) Obtain a complete health history
B) Assess airway patency and breathing
C) Check blood pressure and heart rate
D) Perform a pain assessment
Answer: B) Assess airway patency and breathing
Rationale: The priority in any rapid assessment is to evaluate the ABCs: Airway,
Breathing, and Circulation. Airway patency is the first priority because without a
patent airway, the patient cannot breathe or oxygenate. The nurse should assess for
stridor, wheezing, or absent breath sounds. Only after ensuring the airway is patent
should the nurse proceed to breathing, circulation, and other assessments.
3. A nurse is triaging patients after a mass casualty incident. Which patient
should receive treatment first according to disaster triage principles?
A) A patient with a fractured arm and stable vital signs
B) A patient with an open abdominal wound and hypotension
C) A patient with minor lacerations and ambulatory status
D) A patient with a sprained ankle and normal vital signs
Answer: B) A patient with an open abdominal wound and hypotension
Rationale: In disaster triage, patients are categorized by acuity. The patient with
an open abdominal wound and hypotension is classified as "red" (immediate/life-
threatening) and requires immediate intervention. The patient with a fractured arm
(yellow/delayed), minor lacerations (green/minor), and sprained ankle
(green/minor) have less urgent needs. The goal is to do the greatest good for the
greatest number of patients.
4. A nurse is caring for a patient who suddenly becomes unresponsive. Which
action should the nurse take first?
,A) Call for help and check for a pulse
B) Start chest compressions immediately
C) Administer oxygen via nasal cannula
D) Obtain a blood glucose reading
Answer: A) Call for help and check for a pulse
Rationale: When a patient becomes unresponsive, the first action is to call for help
and simultaneously check for a pulse and breathing. If the patient is pulseless and
not breathing, CPR should be initiated immediately. If a pulse is present but the
patient is not breathing, rescue breaths should be provided. Calling for help ensures
additional resources are available while the nurse begins assessment.
5. A nurse is assessing a patient who is experiencing an acute change in mental
status. Which finding is most concerning?
A) Confusion that improves with orientation
B) Sudden onset of agitation and restlessness
C) Mild drowsiness after pain medication
D) Difficulty finding words occasionally
Answer: B) Sudden onset of agitation and restlessness
Rationale: Sudden onset of agitation and restlessness in a patient with an acute
change in mental status may indicate hypoxia, hypoglycemia, or increased
intracranial pressure. This is a concerning finding that requires immediate
assessment and intervention. Confusion that improves with orientation, mild
drowsiness after pain medication, and occasional word-finding difficulty are less
immediately concerning.
6. A nurse is assessing a patient's level of consciousness using the Glasgow
Coma Scale (GCS). Which finding should the nurse report immediately?
A) GCS score of 15
B) GCS score of 12
, C) GCS score of 8
D) GCS score of 10
Answer: C) GCS score of 8
Rationale: A GCS score of 8 or less indicates severe neurological impairment and
is the threshold for endotracheal intubation to protect the airway. Patients with
GCS ≤8 cannot adequately protect their airway and are at high risk for aspiration.
The nurse should prepare for intubation and mechanical ventilation. GCS scores of
12 and 10 indicate moderate impairment, while 15 is normal.
7. A nurse is assessing a patient who is experiencing chest pain. Which finding
requires immediate intervention?
A) Pain rated 4/10 that is relieved by rest
B) Pain associated with diaphoresis and nausea
C) Pain that worsens with deep breathing
D) Pain that is reproducible with palpation
Answer: B) Pain associated with diaphoresis and nausea
Rationale: Chest pain associated with diaphoresis and nausea is a classic
presentation of acute myocardial infarction and requires immediate intervention.
The nurse should obtain a 12-lead ECG, administer aspirin, and notify the
provider. Pain relieved by rest may indicate stable angina. Pain that worsens with
deep breathing may indicate pleuritic chest pain. Pain reproducible with palpation
may indicate musculoskeletal pain.
8. A nurse is assessing a patient who is postoperative day 1 following
abdominal surgery. Which finding requires immediate notification of the
provider?
A) Temperature of 99.8°F (37.7°C)
B) Heart rate of 92 beats per minute
