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Medical-Surgical Nursing · Medical-Surgical Nursing NCLEX Practice Questions

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Showing all 15 practice questions with expert explanatory rationales.

Question 1 of 15

Case excerpt

During care in a medical unit at 07:20, a patient with suspected acute stroke develops facial droop and unilateral weakness; the family identifies the last-known-well time.

Which nursing action is the priority?

A. The exact last-known-well time
B. The date of the last dental visit
C. The patient's preferred pharmacy
D. The name of the family physician
E. The usual bedtime

Expert Explanatory Rationale

Correct Answer: A. The exact last-known-well time

Last-known-well time is essential for time-sensitive stroke decisions. Activate the stroke response without delay.

Question 2 of 15

Case excerpt

During care in an outpatient clinic at 09:45, a patient with heart failure reports sudden worsening dyspnea and is unable to lie flat; crackles are heard bilaterally.

What is the safest response by the nurse?

A. Place the patient flat
B. Position upright, assess oxygenation, and activate urgent clinical support
C. Delay assessment until the next medication round
D. Encourage ambulation
E. Encourage oral fluids

Expert Explanatory Rationale

Correct Answer: B. Position upright, assess oxygenation, and activate urgent clinical support

Acute pulmonary congestion can impair gas exchange. Support breathing, assess promptly, and escalate care.

Question 3 of 15

Case excerpt

During care in a community health setting at 11:10, a patient with diabetes is confused, diaphoretic, and has a blood glucose of 48 mg/dL; the patient is unable to swallow safely.

Which intervention should the nurse implement first?

A. Encourage walking
B. Administer glucagon or IV dextrose according to protocol and access
C. Wait for the next meal
D. Give orange juice by mouth
E. Administer rapid-acting insulin

Expert Explanatory Rationale

Correct Answer: B. Administer glucagon or IV dextrose according to protocol and access

Severe hypoglycemia with unsafe swallowing requires a nonoral treatment such as IV dextrose or glucagon per protocol.

Question 4 of 15

Case excerpt

During care in an acute-care unit at 13:35, a patient with a chest tube has sudden respiratory distress and the drainage system becomes disconnected.

How should the nurse respond to this finding?

A. Remove the chest tube
B. Clamp the tube for an extended period without an order
C. Restore the system according to emergency chest-drainage policy and urgently assess the patient
D. Strip the tubing forcefully
E. Leave the patient to find supplies

Expert Explanatory Rationale

Correct Answer: C. Restore the system according to emergency chest-drainage policy and urgently assess the patient

A disconnection can compromise the drainage system. Follow emergency policy, assess respiratory status, and obtain immediate assistance.

Question 5 of 15

Case excerpt

During care in a rehabilitation unit at 15:50, a patient with chronic kidney disease has a potassium level of 6.3 mEq/L and peaked T waves.

Which action best protects the patient?

A. Encourage exercise
B. Administer a potassium supplement
C. Repeat the laboratory test next week
D. Offer a potassium-rich snack
E. Notify the provider or rapid response team immediately and prepare for emergency treatment

Expert Explanatory Rationale

Correct Answer: E. Notify the provider or rapid response team immediately and prepare for emergency treatment

Hyperkalemia with ECG changes can cause life-threatening dysrhythmias and requires urgent treatment.

Question 6 of 15

Case excerpt

During care in a specialty care unit at 18:15, a patient with a new lower-leg cast reports severe pain unrelieved by analgesia and pain with passive toe movement.

Which nursing action is the priority?

A. Mild dependent edema only
B. Expected cast discomfort
C. Simple muscle fatigue
D. Compartment syndrome
E. Contact dermatitis

Expert Explanatory Rationale

Correct Answer: D. Compartment syndrome

Severe escalating pain and pain with passive stretch are warning signs of compartment syndrome requiring urgent evaluation.

Question 7 of 15

Case excerpt

During care in a medical unit at 21:05, a patient with COPD has increasing somnolence and shallow respirations after receiving an opioid.

What is the safest response by the nurse?

A. Offer a sedative
B. Administer another opioid dose
C. Assess airway and respiratory status and initiate urgent escalation
D. Remove oxygen without assessment
E. Encourage the patient to sleep

Expert Explanatory Rationale

Correct Answer: C. Assess airway and respiratory status and initiate urgent escalation

Opioids can depress ventilation. Assess respiratory status immediately and follow emergency reversal/escalation protocols.

Question 8 of 15

Case excerpt

During care in an outpatient clinic at 07:20, a patient with suspected gastrointestinal bleeding has coffee-ground emesis, tachycardia, and falling blood pressure.

Which intervention should the nurse implement first?

A. Activate urgent support, assess circulation, and maintain prescribed IV access
B. Administer a laxative
C. Assist the patient to walk
D. Offer oral fluids
E. Delay notification until the next hemoglobin result

Expert Explanatory Rationale

Correct Answer: A. Activate urgent support, assess circulation, and maintain prescribed IV access

Signs of hemodynamic instability with GI bleeding require immediate escalation and circulatory support.

Question 9 of 15

Case excerpt

During care in a community health setting at 09:45, a patient receiving a blood transfusion develops chills, back pain, and dyspnea shortly after initiation.

Which nursing actions are appropriate? (Select all that apply)

A. Slow the transfusion and observe
B. Stop the transfusion and keep IV access open with normal saline using new tubing
C. Reassess the patient after the intervention and compare findings with the baseline
D. Document objective findings, actions taken, and the patient's response
E. Escalate promptly if the patient's condition worsens or remains outside the expected range
F. Discard the blood bag before reporting
G. Delay follow-up until the end of the shift even if the condition is worsening

Expert Explanatory Rationale

Correct Answer: B. Stop the transfusion and keep IV access open with normal saline using new tubing; C. Reassess the patient after the intervention and compare findings with the baseline; D. Document objective findings, actions taken, and the patient's response; E. Escalate promptly if the patient's condition worsens or remains outside the expected range

These findings may indicate a transfusion reaction. Stop the transfusion, maintain access with saline and new tubing, and follow reaction protocol. Reassessment, accurate documentation, and timely escalation support safe, coordinated care.

Question 10 of 15

Case excerpt

During care in an acute-care unit at 11:10, a patient with pneumonia has an oxygen saturation that falls from 95% to 86% and increasing work of breathing.

Which nursing actions are appropriate? (Select all that apply)

A. Reassess the patient after the intervention and compare findings with the baseline
B. Escalate promptly if the patient's condition worsens or remains outside the expected range
C. Promptly assess respiratory status, support oxygenation per order, and escalate care
D. Document the value and return later
E. Delay follow-up until the end of the shift even if the condition is worsening
F. Encourage the patient to lie flat
G. Document objective findings, actions taken, and the patient's response

Expert Explanatory Rationale

Correct Answer: A. Reassess the patient after the intervention and compare findings with the baseline; B. Escalate promptly if the patient's condition worsens or remains outside the expected range; C. Promptly assess respiratory status, support oxygenation per order, and escalate care; G. Document objective findings, actions taken, and the patient's response

A significant oxygenation decline and increased work of breathing require immediate assessment and escalation. Reassessment, accurate documentation, and timely escalation support safe, coordinated care.

Question 11 of 15

Case excerpt

During care in a rehabilitation unit at 13:35, a patient with cirrhosis becomes increasingly confused and has asterixis.

Which nursing actions are appropriate? (Select all that apply)

A. Reassess the patient after the intervention and compare findings with the baseline
B. Delay follow-up until the end of the shift even if the condition is worsening
C. Hepatic encephalopathy
D. Hypoglycemia as the only possible cause
E. Otitis media
F. Escalate promptly if the patient's condition worsens or remains outside the expected range
G. Document objective findings, actions taken, and the patient's response

Expert Explanatory Rationale

Correct Answer: A. Reassess the patient after the intervention and compare findings with the baseline; C. Hepatic encephalopathy; F. Escalate promptly if the patient's condition worsens or remains outside the expected range; G. Document objective findings, actions taken, and the patient's response

Confusion and asterixis in cirrhosis suggest hepatic encephalopathy; assess for triggers and implement prescribed treatment. Reassessment, accurate documentation, and timely escalation support safe, coordinated care.

Question 12 of 15

Case excerpt

During care in a specialty care unit at 15:50, a patient after thyroidectomy develops stridor and difficulty breathing.

Which nursing actions are appropriate? (Select all that apply)

A. Reassess the patient after the intervention and compare findings with the baseline
B. Document objective findings, actions taken, and the patient's response
C. Delay follow-up until the end of the shift even if the condition is worsening
D. Activate emergency airway support and prepare for immediate intervention
E. Place a pillow over the neck
F. Offer sips of water
G. Escalate promptly if the patient's condition worsens or remains outside the expected range

Expert Explanatory Rationale

Correct Answer: A. Reassess the patient after the intervention and compare findings with the baseline; B. Document objective findings, actions taken, and the patient's response; D. Activate emergency airway support and prepare for immediate intervention; G. Escalate promptly if the patient's condition worsens or remains outside the expected range

Stridor after thyroid surgery may indicate airway obstruction from edema or hematoma and is an emergency. Reassessment, accurate documentation, and timely escalation support safe, coordinated care.

Question 13 of 15

Case excerpt

During care in a medical unit at 18:15, a patient with a suspected pulmonary embolism suddenly develops pleuritic chest pain, tachycardia, and hypoxemia.

Which nursing actions are appropriate? (Select all that apply)

A. Reassess the patient after the intervention and compare findings with the baseline
B. Delay follow-up until the end of the shift even if the condition is worsening
C. Massage the affected leg
D. Document objective findings, actions taken, and the patient's response
E. Escalate promptly if the patient's condition worsens or remains outside the expected range
F. Initiate emergency assessment and escalation while supporting oxygenation
G. Encourage unassisted ambulation

Expert Explanatory Rationale

Correct Answer: A. Reassess the patient after the intervention and compare findings with the baseline; D. Document objective findings, actions taken, and the patient's response; E. Escalate promptly if the patient's condition worsens or remains outside the expected range; F. Initiate emergency assessment and escalation while supporting oxygenation

Sudden chest pain, tachycardia, and hypoxemia may indicate pulmonary embolism and require emergency response. Reassessment, accurate documentation, and timely escalation support safe, coordinated care.

Question 14 of 15

Case excerpt

A prescribed IV infusion contains 480 mL and must run evenly over 8 hours. The patient is receiving care related to medical-surgical nursing.

What rate should the nurse program in mL/hr? Enter the number only.

Expert Explanatory Rationale

Correct Answer: 60

Calculate volume divided by time: 480 mL ÷ 8 hr = 60 mL/hr. Verify the prescription, pump settings, and patient response.

Question 15 of 15

Case excerpt

The nurse is completing a safe nursing care sequence for a patient receiving medical-surgical nursing care.

Place the nursing actions in the safest order.

A. Verify the patient's identity, explain the planned care, and assess current status
B. Gather the required equipment and confirm that it is functioning
C. Perform the intervention using the prescribed procedure and appropriate safety measures
D. Reassess the patient and evaluate the response
E. Document the findings, intervention, and outcome

Expert Explanatory Rationale

Correct Answer: A. Verify the patient's identity, explain the planned care, and assess current status; B. Gather the required equipment and confirm that it is functioning; C. Perform the intervention using the prescribed procedure and appropriate safety measures; D. Reassess the patient and evaluate the response; E. Document the findings, intervention, and outcome

The nurse first verifies identity and assesses the patient, prepares equipment, performs the intervention safely, reassesses the response, and documents the care.

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