Prophecy / Relias Medical-Surgical RN B with NGN
Actual Exam 2026/2027 | Complete Exam-Style
Questions with Detailed Rationales | Pass
Guaranteed – A+ Graded
Total Questions: 50 | Time: 90 min | Pass: 80%
TABLE OF CONTENTS
Section 1 | Cardiovascular & Respiratory Med-Surg | Q1 – Q10
Section 2 | GI, Renal & Endocrine Disorders | Q11 – Q20
Section 3 | Neuro, MSK & Integumentary Disorders | Q21 – Q30
Section 4 | NGN Unfolding Case Study: Assessment & Recognition | Q31 – Q40
Section 5 | NGN Unfolding Case Study: Prioritization & Outcomes | Q41 – Q50
Instructions: Choose the single best answer. NGN items include matrix, SATA, and
ordered response simulations. Pass: 80% in 90 minutes.
══════════════════════════════════════
SECTION 1: CARDIOVASCULAR & RESPIRATORY MED-SURG CONDITIONS Q1 – Q10
══════════════════════════════════════
Question 1 of 50
A 68-year-old man is admitted to the telemetry unit with chest pressure radiating to his
left jaw, diaphoresis, and nausea. His vital signs are BP 92/58, HR 110, RR 24, SpO2 91%
on room air. The 12-lead ECG shows ST elevation in leads V1–V4. Which immediate
intervention takes priority?
A. Administer sublingual nitroglycerin 0.4 mg
B. Start a heparin infusion per protocol
C. Activate the cardiac catheterization lab and prepare for primary PCI ✓ CORRECT
D. Obtain a stat chest X-ray to rule out aortic dissection
Correct Answer: C
,Rationale: Anterior ST-elevation myocardial infarction with hemodynamic compromise
requires immediate reperfusion through primary PCI, which is the gold standard when
available within 90 minutes of first medical contact. Sublingual nitroglycerin is
contraindicated with hypotension and right ventricular involvement, and heparin alone
does not restore coronary flow. Door-to-balloon time is a critical quality metric, and
every minute of ischemia increases infarct size and mortality.
Question 2 of 50
A 54-year-old woman on postoperative day 2 after total knee replacement suddenly
develops dyspnea, pleuritic chest pain, and tachycardia at 118 bpm. Her SpO2 drops
from 96% to 88% on 2L nasal cannula. Which assessment finding would most support a
pulmonary embolism diagnosis?
A. Bilateral crackles on auscultation
B. Unilateral calf swelling and Homans' sign ✓ CORRECT
C. Expiratory wheezing throughout all lung fields
D. Decreased breath sounds at the lung bases bilaterally
Correct Answer: B
Rationale: Unilateral calf swelling, tenderness, and a positive Homans' sign indicate
deep vein thrombosis, the source of most pulmonary emboli, and in the context of acute
dyspnea and hypoxia strongly support PE diagnosis. Bilateral crackles suggest
pulmonary edema, while wheezing indicates bronchospasm. Postoperative patients are
at high risk for VTE, and the Wells criteria or PERC rule should be applied to determine
need for CT pulmonary angiography or D-dimer testing.
Question 3 of 50
A 72-year-old man with a history of atrial fibrillation on warfarin presents with acute
onset left-sided weakness and slurred speech. His INR is 3.8. The CT scan shows no
hemorrhage. Which immediate intervention is indicated?
,A. Administer aspirin 325 mg orally
B. Give IV tissue plasminogen activator if within the therapeutic window ✓ CORRECT
C. Start a heparin drip and hold warfarin
D. Perform emergent carotid endarterectomy
Correct Answer: B
Rationale: Acute ischemic stroke in a patient with atrial fibrillation and therapeutic INR is
still a candidate for IV tPA if within 4.5 hours of symptom onset and no
contraindications exist; the elevated INR does not automatically exclude treatment if it
is below 4.5. Aspirin is appropriate after tPA or if tPA is contraindicated, but not as
first-line for eligible candidates. Heparin is not indicated in acute ischemic stroke
management. Time is brain, and door-to-needle time should be under 60 minutes.
Question 4 of 50
A 61-year-old woman with heart failure is receiving IV furosemide 40 mg twice daily. Her
morning labs show potassium 3.1 mEq/L, magnesium 1.4 mg/dL, and creatinine 1.3
mg/dL. Which electrolyte replacement should be addressed first?
A. Potassium chloride 40 mEq orally
B. Magnesium sulfate 2 g IV ✓ CORRECT
C. Sodium bicarbonate 50 mEq IV
D. Calcium gluconate 1 g IV
Correct Answer: B
Rationale: Hypomagnesemia must be corrected before or concurrently with potassium
repletion because magnesium is a cofactor for Na-K-ATPase, and hypokalemia will not
correct if magnesium remains depleted. Sodium bicarbonate is inappropriate without
acidosis, and calcium is reserved for hyperkalemia with ECG changes. Loop diuretics
cause both potassium and magnesium wasting, and routine monitoring of both
electrolytes is essential in heart failure patients receiving aggressive diuresis.
Question 5 of 50
, A 45-year-old man with a history of hypertension presents to the med-surg unit with a
blood pressure of 210/130 mmHg, headache, and blurred vision. Fundoscopic exam
reveals papilledema. Which medication is first-line for this hypertensive emergency?
A. Oral lisinopril 20 mg
B. IV nicardipine infusion titrated to effect ✓ CORRECT
C. Sublingual nifedipine 10 mg
D. Oral metoprolol 50 mg
Correct Answer: B
Rationale: Hypertensive emergency with end-organ damage requires controlled IV blood
pressure reduction with a titratable agent such as nicardipine or labetalol to prevent
cerebral hypoperfusion from overly rapid correction. Oral agents and sublingual
nifedipine are contraindicated due to unpredictable and precipitous drops in blood
pressure. The goal is to reduce mean arterial pressure by no more than 20–25% in the
first hour, with further gradual reduction over 24–48 hours.
Question 6 of 50
A 58-year-old woman with COPD is admitted with an exacerbation. Her arterial blood
gas on 2L nasal cannula shows pH 7.32, PaCO2 58 mmHg, PaO2 62 mmHg, and HCO3
30 mEq/L. Which ventilatory strategy is most appropriate?
A. Increase oxygen to maintain SpO2 above 94%
B. Initiate bilevel positive airway pressure (BiPAP) ✓ CORRECT
C. Prepare for immediate endotracheal intubation
D. Administer high-flow nasal cannula at 60 L/min
Correct Answer: B
Rationale: This ABG demonstrates acute-on-chronic respiratory acidosis with
compensated hypercapnia; BiPAP reduces work of breathing, improves alveolar
ventilation, and decreases PaCO2 while avoiding intubation in the appropriate patient.
High-concentration oxygen can worsen hypercapnia by removing hypoxic respiratory
Actual Exam 2026/2027 | Complete Exam-Style
Questions with Detailed Rationales | Pass
Guaranteed – A+ Graded
Total Questions: 50 | Time: 90 min | Pass: 80%
TABLE OF CONTENTS
Section 1 | Cardiovascular & Respiratory Med-Surg | Q1 – Q10
Section 2 | GI, Renal & Endocrine Disorders | Q11 – Q20
Section 3 | Neuro, MSK & Integumentary Disorders | Q21 – Q30
Section 4 | NGN Unfolding Case Study: Assessment & Recognition | Q31 – Q40
Section 5 | NGN Unfolding Case Study: Prioritization & Outcomes | Q41 – Q50
Instructions: Choose the single best answer. NGN items include matrix, SATA, and
ordered response simulations. Pass: 80% in 90 minutes.
══════════════════════════════════════
SECTION 1: CARDIOVASCULAR & RESPIRATORY MED-SURG CONDITIONS Q1 – Q10
══════════════════════════════════════
Question 1 of 50
A 68-year-old man is admitted to the telemetry unit with chest pressure radiating to his
left jaw, diaphoresis, and nausea. His vital signs are BP 92/58, HR 110, RR 24, SpO2 91%
on room air. The 12-lead ECG shows ST elevation in leads V1–V4. Which immediate
intervention takes priority?
A. Administer sublingual nitroglycerin 0.4 mg
B. Start a heparin infusion per protocol
C. Activate the cardiac catheterization lab and prepare for primary PCI ✓ CORRECT
D. Obtain a stat chest X-ray to rule out aortic dissection
Correct Answer: C
,Rationale: Anterior ST-elevation myocardial infarction with hemodynamic compromise
requires immediate reperfusion through primary PCI, which is the gold standard when
available within 90 minutes of first medical contact. Sublingual nitroglycerin is
contraindicated with hypotension and right ventricular involvement, and heparin alone
does not restore coronary flow. Door-to-balloon time is a critical quality metric, and
every minute of ischemia increases infarct size and mortality.
Question 2 of 50
A 54-year-old woman on postoperative day 2 after total knee replacement suddenly
develops dyspnea, pleuritic chest pain, and tachycardia at 118 bpm. Her SpO2 drops
from 96% to 88% on 2L nasal cannula. Which assessment finding would most support a
pulmonary embolism diagnosis?
A. Bilateral crackles on auscultation
B. Unilateral calf swelling and Homans' sign ✓ CORRECT
C. Expiratory wheezing throughout all lung fields
D. Decreased breath sounds at the lung bases bilaterally
Correct Answer: B
Rationale: Unilateral calf swelling, tenderness, and a positive Homans' sign indicate
deep vein thrombosis, the source of most pulmonary emboli, and in the context of acute
dyspnea and hypoxia strongly support PE diagnosis. Bilateral crackles suggest
pulmonary edema, while wheezing indicates bronchospasm. Postoperative patients are
at high risk for VTE, and the Wells criteria or PERC rule should be applied to determine
need for CT pulmonary angiography or D-dimer testing.
Question 3 of 50
A 72-year-old man with a history of atrial fibrillation on warfarin presents with acute
onset left-sided weakness and slurred speech. His INR is 3.8. The CT scan shows no
hemorrhage. Which immediate intervention is indicated?
,A. Administer aspirin 325 mg orally
B. Give IV tissue plasminogen activator if within the therapeutic window ✓ CORRECT
C. Start a heparin drip and hold warfarin
D. Perform emergent carotid endarterectomy
Correct Answer: B
Rationale: Acute ischemic stroke in a patient with atrial fibrillation and therapeutic INR is
still a candidate for IV tPA if within 4.5 hours of symptom onset and no
contraindications exist; the elevated INR does not automatically exclude treatment if it
is below 4.5. Aspirin is appropriate after tPA or if tPA is contraindicated, but not as
first-line for eligible candidates. Heparin is not indicated in acute ischemic stroke
management. Time is brain, and door-to-needle time should be under 60 minutes.
Question 4 of 50
A 61-year-old woman with heart failure is receiving IV furosemide 40 mg twice daily. Her
morning labs show potassium 3.1 mEq/L, magnesium 1.4 mg/dL, and creatinine 1.3
mg/dL. Which electrolyte replacement should be addressed first?
A. Potassium chloride 40 mEq orally
B. Magnesium sulfate 2 g IV ✓ CORRECT
C. Sodium bicarbonate 50 mEq IV
D. Calcium gluconate 1 g IV
Correct Answer: B
Rationale: Hypomagnesemia must be corrected before or concurrently with potassium
repletion because magnesium is a cofactor for Na-K-ATPase, and hypokalemia will not
correct if magnesium remains depleted. Sodium bicarbonate is inappropriate without
acidosis, and calcium is reserved for hyperkalemia with ECG changes. Loop diuretics
cause both potassium and magnesium wasting, and routine monitoring of both
electrolytes is essential in heart failure patients receiving aggressive diuresis.
Question 5 of 50
, A 45-year-old man with a history of hypertension presents to the med-surg unit with a
blood pressure of 210/130 mmHg, headache, and blurred vision. Fundoscopic exam
reveals papilledema. Which medication is first-line for this hypertensive emergency?
A. Oral lisinopril 20 mg
B. IV nicardipine infusion titrated to effect ✓ CORRECT
C. Sublingual nifedipine 10 mg
D. Oral metoprolol 50 mg
Correct Answer: B
Rationale: Hypertensive emergency with end-organ damage requires controlled IV blood
pressure reduction with a titratable agent such as nicardipine or labetalol to prevent
cerebral hypoperfusion from overly rapid correction. Oral agents and sublingual
nifedipine are contraindicated due to unpredictable and precipitous drops in blood
pressure. The goal is to reduce mean arterial pressure by no more than 20–25% in the
first hour, with further gradual reduction over 24–48 hours.
Question 6 of 50
A 58-year-old woman with COPD is admitted with an exacerbation. Her arterial blood
gas on 2L nasal cannula shows pH 7.32, PaCO2 58 mmHg, PaO2 62 mmHg, and HCO3
30 mEq/L. Which ventilatory strategy is most appropriate?
A. Increase oxygen to maintain SpO2 above 94%
B. Initiate bilevel positive airway pressure (BiPAP) ✓ CORRECT
C. Prepare for immediate endotracheal intubation
D. Administer high-flow nasal cannula at 60 L/min
Correct Answer: B
Rationale: This ABG demonstrates acute-on-chronic respiratory acidosis with
compensated hypercapnia; BiPAP reduces work of breathing, improves alveolar
ventilation, and decreases PaCO2 while avoiding intubation in the appropriate patient.
High-concentration oxygen can worsen hypercapnia by removing hypoxic respiratory
