NIGHTINGALE BSN 346 MED-SURG II
PRACTICE TEST 2025 |(LATEST UPDATE
) QUESTIONS & ANSWERS | 100%
CORRECT | GRADE A +
Question 1
A patient with chronic kidney disease presents with hyperkalemia (K⁺ 6.5
mEq/L) and peaked T waves on ECG. Which action is priority?
A. Administer loop diuretic as prescribed
B. Initiate IV calcium gluconate
C. Encourage oral potassium intake
D. Document and monitor
Correct Answer: B
Rationale: Hyperkalemia with ECG changes is life-threatening; IV
calcium stabilizes cardiac membranes immediately.
Question 2
A patient post-MI reports chest pain radiating to the left arm. Which is
priority?
A. Obtain ECG and administer prescribed nitroglycerin
B. Encourage deep breathing
C. Apply cold compress
D. Document findings
Correct Answer: A
Rationale: Chest pain with radiation after MI may indicate ongoing
ischemia; rapid ECG and nitroglycerin are priority.
Question 3
A patient with COPD on 2 L O₂ via nasal cannula becomes drowsy.
Priority nursing action?
A. Increase oxygen to 4 L
B. Stimulate patient and assess respiratory status
,C. Encourage coughing
D. Document findings
Correct Answer: B
Rationale: Hypoventilation may indicate CO₂ retention; assessing
respiratory status before oxygen adjustment is critical.
Question 4
A post-op patient develops sudden shortness of breath, tachycardia, and
hypotension. What is the priority action?
A. Administer oxygen and call rapid response
B. Encourage deep breathing
C. Assess surgical incision
D. Administer analgesic
Correct Answer: A
Rationale: Signs suggest pulmonary embolism; immediate oxygen and
rapid response are life-saving.
Question 5
A patient receiving IV heparin develops hematuria and ecchymoses.
What is the priority nursing action?
A. Hold heparin and notify provider
B. Apply pressure to bruises
C. Document and continue
D. Encourage ambulation
Correct Answer: A
Rationale: Bleeding is a serious complication; holding heparin and
notifying provider prevents further hemorrhage.
Question 6
A patient with heart failure has 3+ pitting edema and dyspnea. Which
action is priority?
,A. Assess lung sounds and oxygen saturation
B. Elevate legs and monitor skin
C. Encourage ambulation
D. Administer PRN analgesic
Correct Answer: A
Rationale: Fluid overload can precipitate pulmonary edema; assessing
respiratory status is critical for safety.
Question 7
A patient with DKA has glucose 480 mg/dL and potassium 2.9 mEq/L.
Which action should be taken first?
A. Administer IV insulin
B. Administer IV potassium
C. Encourage oral fluids
D. Monitor vitals
Correct Answer: B
Rationale: Insulin shifts potassium intracellularly; hypokalemia must be
corrected first to prevent arrhythmias.
Question 8
A patient on digoxin reports nausea, vomiting, and blurred vision.
Priority action?
A. Hold digoxin and notify provider
B. Encourage fluids
C. Document
D. Reassess in 4 hours
Correct Answer: A
Rationale: Symptoms indicate digoxin toxicity; withholding the
medication prevents cardiac complications.
, Question 9
A patient with hepatic encephalopathy exhibits confusion and asterixis.
Which intervention is priority?
A. Assess neurological status and initiate ammonia-lowering therapy
B. Encourage ambulation
C. Document findings
D. Provide oral nutrition
Correct Answer: A
Rationale: Early recognition and treatment of hepatic encephalopathy
prevent further neurologic deterioration.
Question 10
A patient develops sudden stridor and dyspnea after tracheostomy. What
is the priority action?
A. Call for immediate respiratory support
B. Suction tracheostomy
C. Elevate head of bed
D. Encourage coughing
Correct Answer: A
Rationale: Stridor indicates airway obstruction; rapid intervention is
critical for patient survival.
Question 11
A patient receiving vancomycin IV develops flushing, hypotension, and
rash. First action?
A. Stop infusion and assess vital signs
B. Administer antihistamine
C. Slow infusion
D. Document and monitor
Correct Answer: A
Rationale: Red man syndrome can escalate; stopping infusion prevents
severe adverse effects.
PRACTICE TEST 2025 |(LATEST UPDATE
) QUESTIONS & ANSWERS | 100%
CORRECT | GRADE A +
Question 1
A patient with chronic kidney disease presents with hyperkalemia (K⁺ 6.5
mEq/L) and peaked T waves on ECG. Which action is priority?
A. Administer loop diuretic as prescribed
B. Initiate IV calcium gluconate
C. Encourage oral potassium intake
D. Document and monitor
Correct Answer: B
Rationale: Hyperkalemia with ECG changes is life-threatening; IV
calcium stabilizes cardiac membranes immediately.
Question 2
A patient post-MI reports chest pain radiating to the left arm. Which is
priority?
A. Obtain ECG and administer prescribed nitroglycerin
B. Encourage deep breathing
C. Apply cold compress
D. Document findings
Correct Answer: A
Rationale: Chest pain with radiation after MI may indicate ongoing
ischemia; rapid ECG and nitroglycerin are priority.
Question 3
A patient with COPD on 2 L O₂ via nasal cannula becomes drowsy.
Priority nursing action?
A. Increase oxygen to 4 L
B. Stimulate patient and assess respiratory status
,C. Encourage coughing
D. Document findings
Correct Answer: B
Rationale: Hypoventilation may indicate CO₂ retention; assessing
respiratory status before oxygen adjustment is critical.
Question 4
A post-op patient develops sudden shortness of breath, tachycardia, and
hypotension. What is the priority action?
A. Administer oxygen and call rapid response
B. Encourage deep breathing
C. Assess surgical incision
D. Administer analgesic
Correct Answer: A
Rationale: Signs suggest pulmonary embolism; immediate oxygen and
rapid response are life-saving.
Question 5
A patient receiving IV heparin develops hematuria and ecchymoses.
What is the priority nursing action?
A. Hold heparin and notify provider
B. Apply pressure to bruises
C. Document and continue
D. Encourage ambulation
Correct Answer: A
Rationale: Bleeding is a serious complication; holding heparin and
notifying provider prevents further hemorrhage.
Question 6
A patient with heart failure has 3+ pitting edema and dyspnea. Which
action is priority?
,A. Assess lung sounds and oxygen saturation
B. Elevate legs and monitor skin
C. Encourage ambulation
D. Administer PRN analgesic
Correct Answer: A
Rationale: Fluid overload can precipitate pulmonary edema; assessing
respiratory status is critical for safety.
Question 7
A patient with DKA has glucose 480 mg/dL and potassium 2.9 mEq/L.
Which action should be taken first?
A. Administer IV insulin
B. Administer IV potassium
C. Encourage oral fluids
D. Monitor vitals
Correct Answer: B
Rationale: Insulin shifts potassium intracellularly; hypokalemia must be
corrected first to prevent arrhythmias.
Question 8
A patient on digoxin reports nausea, vomiting, and blurred vision.
Priority action?
A. Hold digoxin and notify provider
B. Encourage fluids
C. Document
D. Reassess in 4 hours
Correct Answer: A
Rationale: Symptoms indicate digoxin toxicity; withholding the
medication prevents cardiac complications.
, Question 9
A patient with hepatic encephalopathy exhibits confusion and asterixis.
Which intervention is priority?
A. Assess neurological status and initiate ammonia-lowering therapy
B. Encourage ambulation
C. Document findings
D. Provide oral nutrition
Correct Answer: A
Rationale: Early recognition and treatment of hepatic encephalopathy
prevent further neurologic deterioration.
Question 10
A patient develops sudden stridor and dyspnea after tracheostomy. What
is the priority action?
A. Call for immediate respiratory support
B. Suction tracheostomy
C. Elevate head of bed
D. Encourage coughing
Correct Answer: A
Rationale: Stridor indicates airway obstruction; rapid intervention is
critical for patient survival.
Question 11
A patient receiving vancomycin IV develops flushing, hypotension, and
rash. First action?
A. Stop infusion and assess vital signs
B. Administer antihistamine
C. Slow infusion
D. Document and monitor
Correct Answer: A
Rationale: Red man syndrome can escalate; stopping infusion prevents
severe adverse effects.
