Medical-Surgical Nursing – RN Practice Questions

These practice questions are written at NCLEX-RN level and emphasize multi-step clinical reasoning, prioritization across patients, delegation and supervision, and recognition of complications requiring escalation. Options are numbered; the answer identifies the option by number and restates it.

Question 1

A registered nurse receives report on four patients at the start of the shift. Which patient should the nurse assess first?

1. A patient two days after a total knee arthroplasty who reports incisional pain rated 7 out of 10.
2. A patient with chronic obstructive pulmonary disease whose oxygen saturation is 90 percent on 2 liters per minute by nasal cannula.
3. A patient admitted with a right femur fracture 36 hours ago who is now restless and reports feeling short of breath.
4. A patient with type 2 diabetes whose morning blood glucose is 210 mg/dL.

Answer: Option 3, the patient with a femur fracture who is restless and dyspneic.

Rationale: New restlessness with dyspnea 24 to 72 hours after a long bone fracture is the classic presentation of fat embolism syndrome, and restlessness is an early sign of hypoxia. This patient has an actual, unstable airway and breathing problem requiring immediate assessment and escalation. Option 1 is expected postoperative pain and is treatable but not life threatening. Option 2 is an acceptable saturation for a patient with chronic obstructive pulmonary disease, whose target is often 88 to 92 percent. Option 4 is an abnormal but non-emergent glucose in a patient with known diabetes.

Question 2

A patient presents to the emergency department with substernal chest pain that began three hours ago. The initial troponin is within normal limits. What is the nurse's best interpretation of this result?

1. The pain is not cardiac in origin, so cardiac monitoring can be discontinued.
2. Myocardial infarction is ruled out and the patient can be discharged.
3. Troponin may not yet be elevated this early, so serial levels and continued monitoring are required.
4. The troponin result is invalid and the specimen should be redrawn immediately.

Answer: Option 3, troponin may not yet be elevated this early, so serial levels and continued monitoring are required.

Rationale: Troponin begins to rise roughly three to four hours after myocardial injury, peaks around twelve to twenty-four hours, and remains elevated for up to ten to fourteen days. A single early normal value does not exclude infarction, so serial troponins, serial electrocardiograms, and continuous rhythm monitoring continue. Options 1 and 2 are unsafe because they act on an incomplete data set. Option 4 assumes laboratory error without evidence.

Question 3

A nurse is caring for a patient admitted with an exacerbation of heart failure. Which findings should the nurse report to the provider immediately? Select all that apply.

1. Weight gain of 4 pounds since yesterday.
2. Pink frothy sputum with new crackles throughout both lung fields.
3. Trace bilateral ankle edema that has been present for months.
4. Oxygen saturation that has fallen from 95 percent to 86 percent on room air.
5. Serum potassium of 2.9 mEq/L in a patient receiving furosemide.

Answer: Options 1, 2, 4, and 5.

Rationale: A gain of two to three pounds in a day signals acute fluid retention and decompensation. Pink frothy sputum with diffuse crackles indicates acute pulmonary edema, an emergency. A saturation falling to 86 percent is significant hypoxemia. A potassium of 2.9 mEq/L is dangerously low, predisposes to lethal dysrhythmias, and increases digoxin toxicity risk if digoxin is prescribed. Option 3 is a chronic, stable, expected finding in heart failure and does not require immediate notification.

Question 4

A patient with a spinal cord injury at the level of the fourth thoracic vertebra suddenly reports a pounding headache. The blood pressure is 208/112 mm Hg, the pulse is 48 beats per minute, and the face is flushed and diaphoretic while the legs are cool and pale. What should the nurse do first?

1. Administer the prescribed as-needed antihypertensive medication.
2. Place the patient in a sitting position with the head of the bed elevated.
3. Check the indwelling urinary catheter tubing for kinks or obstruction.
4. Notify the provider and prepare for transfer to the intensive care unit.

Answer: Option 2, place the patient in a sitting position with the head of the bed elevated.

Rationale: These findings are autonomic dysreflexia, a life-threatening emergency in injuries at or above the sixth thoracic vertebra. Sitting the patient upright uses orthostatic pooling to lower blood pressure immediately and takes only seconds. Removing the noxious stimulus, most often a distended bladder or impacted bowel, is the next action (option 3), followed by notification (option 4) and medication if pressure remains elevated (option 1). All four actions occur, but positioning is done first because it is immediate and requires no order.

Question 5

Six hours after casting of a tibial fracture, a patient reports severe pain that is unrelieved by two doses of intravenous morphine and worsens sharply when the toes are passively extended. The toes are warm with a palpable pedal pulse and capillary refill of two seconds. What is the nurse's priority action?

1. Document the findings and reassess in one hour, since the pulse and perfusion are intact.
2. Elevate the extremity well above the level of the heart and apply ice.
3. Notify the provider immediately about possible compartment syndrome.
4. Administer an additional dose of morphine and encourage relaxation techniques.

Answer: Option 3, notify the provider immediately about possible compartment syndrome.

Rationale: Pain out of proportion to the injury, unrelieved by opioids and increased by passive stretch, is the earliest and most reliable indicator of compartment syndrome. A palpable pulse does not rule it out, because pulselessness is a very late finding after irreversible tissue damage has begun. Option 1 delays a limb-threatening emergency. Option 2 is harmful, because elevating above heart level further reduces arterial perfusion; the extremity is kept at heart level. Option 4 masks the key assessment finding without addressing the cause.

Question 6

A patient in diabetic ketoacidosis has a blood glucose of 486 mg/dL, arterial pH of 7.14, and serum potassium of 3.1 mEq/L. The provider orders an intravenous regular insulin infusion. What is the nurse's most appropriate action?

1. Begin the insulin infusion as ordered and recheck potassium in four hours.
2. Hold the insulin infusion, notify the provider, and anticipate potassium replacement first.
3. Give the insulin subcutaneously instead to slow the rate of glucose reduction.
4. Administer sodium bicarbonate before starting the insulin infusion.

Answer: Option 2, hold the insulin infusion, notify the provider, and anticipate potassium replacement first.

Rationale: Insulin drives potassium from the extracellular space into cells. Starting insulin when the serum potassium is already below approximately 3.3 mEq/L can precipitate profound hypokalemia with lethal dysrhythmias and respiratory muscle weakness. Potassium is replaced first and the infusion is then started. Option 1 exposes the patient to that risk. Option 3 is inappropriate because intravenous regular insulin is the standard route in ketoacidosis and the route change does not address the potassium problem. Option 4 is not routine and is reserved for severe acidosis under specific circumstances.

Question 7

A nurse observes continuous vigorous bubbling in the water seal chamber of a patient's closed chest drainage system. The patient is dyspneic with decreased breath sounds on the affected side. What should the nurse do first?

1. Clamp the chest tube near the insertion site and observe for improvement.
2. Increase the wall suction to improve lung reexpansion.
3. Assess the tubing and all connections for a leak, beginning at the chest.
4. Strip the chest tube to clear any obstructing clot.

Answer: Option 3, assess the tubing and all connections for a leak, beginning at the chest.

Rationale: Continuous bubbling in the water seal chamber indicates air entering the system, which is an air leak. The nurse systematically assesses the dressing, insertion site, connections, and tubing to locate it. Option 1 is dangerous, because prolonged clamping traps air and can produce a tension pneumothorax. Option 2 does not correct a leak and may worsen air entrainment. Option 4 is contraindicated, because stripping generates high negative pressure and can damage lung tissue.

Question 8

A registered nurse is making assignments on a medical-surgical unit. Which tasks may the nurse appropriately delegate to unlicensed assistive personnel? Select all that apply.

1. Obtaining vital signs on a stable patient two days after a cholecystectomy.
2. Assisting a stable postoperative patient to ambulate in the hallway.
3. Performing the admission assessment on a newly arrived patient.
4. Recording intake and output for a patient with heart failure.
5. Reinforcing preoperative teaching about incentive spirometry for the first time.

Answer: Options 1, 2, and 4.

Rationale: Unlicensed assistive personnel may perform standardized, predictable tasks for stable patients that do not require nursing judgment, including vital signs, assisted ambulation, and intake and output measurement. Option 3 is not delegable, because the initial admission assessment requires the registered nurse's judgment and cannot be transferred. Option 5 is not delegable, because initial patient teaching is a registered nurse responsibility; unlicensed personnel may not teach, and even reinforcement of teaching belongs to licensed staff.

Question 9

A patient with a traumatic brain injury has a blood pressure that has risen from 128/76 to 176/68 mm Hg, a heart rate that has fallen from 88 to 50 beats per minute, and irregular respirations. What is the nurse's interpretation and priority action?

1. These are expected findings after head trauma; continue routine monitoring.
2. This is Cushing triad indicating impending herniation; notify the provider immediately.
3. The patient is developing hypovolemic shock; increase the intravenous fluid rate.
4. The patient is having a vasovagal response; lower the head of the bed flat.

Answer: Option 2, this is Cushing triad indicating impending herniation; notify the provider immediately.

Rationale: Rising systolic pressure with a widening pulse pressure, bradycardia, and irregular respirations form Cushing triad, a late and ominous sign of severely elevated intracranial pressure with impending brainstem herniation. Immediate escalation is required. Option 1 fails to rescue. Option 3 is incorrect, because hypovolemic shock produces hypotension with tachycardia, and additional fluid could worsen cerebral edema. Option 4 is wrong and harmful; lying flat further increases intracranial pressure, and the head of the bed should remain elevated about thirty degrees with the head midline.

Question 10

Fifteen minutes after a unit of packed red blood cells is started, a patient develops chills, a temperature increase of 2 degrees Fahrenheit, low back pain, and dark red urine. Which action should the nurse take first?

1. Notify the provider and the blood bank.
2. Stop the transfusion immediately.
3. Obtain a urine specimen for analysis.
4. Administer the prescribed antipyretic.

Answer: Option 2, stop the transfusion immediately.

Rationale: Chills, fever, flank or low back pain, and hemoglobinuria indicate an acute hemolytic transfusion reaction, which is life threatening. Stopping the infusion halts further exposure and is always the first action. The nurse then keeps the line open with normal saline using new tubing, assesses vital signs, notifies the provider and blood bank (option 1), and collects specimens including urine (option 3). Option 4 treats a symptom without stopping the cause and is not first.

Question 11

A patient with cirrhosis and known esophageal varices suddenly vomits a large volume of bright red blood. The blood pressure is 84/50 mm Hg and the pulse is 128 beats per minute. Which action should the nurse take first?

1. Position the patient with the head of the bed elevated and the head turned to the side.
2. Insert a large-bore intravenous catheter and begin fluid resuscitation.
3. Obtain a stat type and crossmatch and hemoglobin level.
4. Administer the prescribed lactulose to reduce ammonia levels.

Answer: Option 1, position the patient with the head of the bed elevated and the head turned to the side.

Rationale: Airway protection comes first. A patient actively vomiting large volumes of blood is at immediate risk for aspiration, so positioning to protect the airway with suction available precedes circulatory support. Fluid resuscitation (option 2) and laboratory studies (option 3) follow rapidly and are essential, but they come after the airway is secured. Option 4 addresses hepatic encephalopathy, not acute hemorrhage, and giving oral medication to an actively vomiting patient is unsafe.

Question 12

A patient receiving chemotherapy has an absolute neutrophil count of 380 cells per microliter. Which interventions should the nurse implement? Select all that apply.

1. Report a temperature of 100.5 degrees Fahrenheit to the provider promptly.
2. Remove fresh flowers and standing water from the patient's room.
3. Take the temperature rectally every four hours for accuracy.
4. Screen all visitors for signs of respiratory or gastrointestinal illness.
5. Perform meticulous hand hygiene before all patient contact.

Answer: Options 1, 2, 4, and 5.

Rationale: With severe neutropenia the inflammatory response is blunted, so even a low-grade fever may be the only sign of serious infection and is treated as an emergency. Fresh flowers and standing water harbor organisms, visitor screening reduces exposure, and hand hygiene is the single most effective preventive measure. Option 3 is contraindicated, because rectal temperatures, suppositories, and enemas can cause mucosal trauma and introduce bacteria into the bloodstream in a neutropenic patient.

Question 13

A patient taking digoxin and furosemide reports nausea, anorexia, and seeing yellow-green halos around lights. The apical pulse is 52 beats per minute and irregular. Which laboratory value most likely contributed to this presentation?

1. Serum sodium of 138 mEq/L.
2. Serum potassium of 2.8 mEq/L.
3. Serum calcium of 9.2 mg/dL.
4. Serum magnesium of 2.0 mEq/L.

Answer: Option 2, serum potassium of 2.8 mEq/L.

Rationale: The patient shows classic digoxin toxicity with gastrointestinal symptoms, yellow-green visual halos, and bradycardia with a new irregular rhythm. Hypokalemia, commonly caused by loop diuretics such as furosemide, markedly potentiates digoxin binding and toxicity even when the digoxin level is within range. The nurse holds the dose, notifies the provider, and obtains a digoxin level. Options 1, 3, and 4 are all within normal limits and do not explain the findings.

Question 14

Four hours after a total thyroidectomy, a patient reports tingling around the mouth and in the fingertips, and carpal spasm occurs when the blood pressure cuff is inflated. What should the nurse anticipate?

1. Administration of intravenous calcium gluconate for hypocalcemia.
2. Administration of intravenous levothyroxine for myxedema.
3. Application of a cooling blanket for thyroid storm.
4. Administration of potassium chloride for hypokalemia.

Answer: Option 1, administration of intravenous calcium gluconate for hypocalcemia.

Rationale: Perioral and fingertip paresthesia with a positive Trousseau sign indicates acute hypocalcemia, which occurs when the parathyroid glands are injured or inadvertently removed during thyroidectomy. Untreated, it progresses to tetany, laryngospasm, and seizures, so calcium replacement and continued airway vigilance are the priorities. Option 2 describes severe hypothyroidism, which does not develop within hours. Option 3 describes thyroid storm, which presents with high fever, severe tachycardia, and agitation. Option 4 does not match the findings.

Question 15

A patient with acute kidney injury has a serum potassium of 6.9 mEq/L, and the cardiac monitor shows peaked T waves with a widening QRS complex. The provider orders several medications. Which one should the nurse recognize as the immediate measure to protect the heart, understanding that it does not lower the serum potassium?

1. Intravenous calcium gluconate.
2. Intravenous regular insulin with dextrose.
3. Oral sodium polystyrene sulfonate or a newer potassium binder.
4. Intravenous sodium bicarbonate.

Answer: Option 1, intravenous calcium gluconate.

Rationale: Calcium gluconate stabilizes the myocardial cell membrane and rapidly reduces the risk of lethal dysrhythmia, but it does not change the serum potassium level. Insulin with dextrose and bicarbonate shift potassium into cells, temporarily lowering the serum level, and binders or dialysis actually remove potassium from the body. Understanding this distinction matters, because cardiac protection is given first while the potassium-lowering measures take effect.

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