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MEDICAL-SURGICAL NURSING III (NSG233) EXAM PACK – 100
NCLEX-STYLE QUESTIONS & ANSWERS [LATEST
2025/2026]100% CORRECT ALREADY GRADED A+
Question 1 — Acute Myocardial Infarction (STEMI)
A 62-year-old man arrives in the ED with crushing substernal chest pain
radiating to his left jaw and arm for 45 minutes. He is diaphoretic and
anxious. ECG shows ST-segment elevation in leads II, III, and aVF. Blood
pressure 110/68 mmHg, HR 92. Which action should the nurse perform
first?
A. Administer chewable aspirin 325 mg immediately.
B. Prepare the patient for immediate thrombolytic therapy.
C. Start a heparin infusion.
D. Give sublingual nitroglycerin.
E. Obtain blood for troponin and chemistries.
Correct answer: A. Administer chewable aspirin 325 mg immediately.
Rationale:
Aspirin (chewable) given immediately is the highest-priority, evidence-
based intervention in suspected acute MI — it inhibits platelet aggregation
and reduces mortality when given early. The patient is within the window
and not hypotensive. Chewable aspirin has faster absorption. While
reperfusion (PCI/thrombolysis) is critical, the first action at bedside is
aspirin.
B (thrombolytics): Indicated in STEMI when PCI unavailable within
guideline times, but not the first immediate action at bedside — also
contraindications must be assessed.
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C (heparin): Anticoagulation is used in MI management but not before
aspirin; placement requires orders and IV access.
D (sublingual NTG): Good for pain and ischemia but nitroglycerin is
relatively contraindicated if inferior MI with right ventricle
involvement — leads II, III, aVF suggest inferior MI; give only after
assessing for RV infarct (check JVD, hypotension) and with physician
order.
E (labs): Important but not first — do concurrently when possible.
Nursing priorities/teaching: Give chewable aspirin immediately (unless
true allergy), call cath lab/notify cardiology for PCI, monitor vitals/ECG,
establish IV access, prepare for reperfusion. Educate patient about aspirin
purpose.
Question 2 — Acute Decompensated Heart Failure (Pulmonary Edema)
A 74-year-old woman with chronic heart failure is admitted with acute
dyspnea. She is anxious, has pink frothy sputum, RR 32, SpO₂ 85% on room
air, bilateral crackles to mid-lung fields, and JVD present. Which
intervention is highest priority?
A. Elevate head of bed and apply high-flow oxygen (nonrebreather or
CPAP).
B. Administer IV furosemide 40 mg push.
C. Give a subcutaneous dose of low-molecular-weight heparin.
D. Obtain a chest x-ray.
E. Start an oral ACE inhibitor.
Correct answer: A. Elevate head of bed and apply high-flow oxygen
(nonrebreather or CPAP).
Rationale:
This patient demonstrates acute pulmonary edema with hypoxemia.
Immediate airway/oxygenation support and decreasing preload (upright
position) take priority to improve oxygenation and reduce work of breathing.
,3|Page
CPAP or BiPAP can improve oxygenation and reduce preload/afterload
quickly.
B (IV furosemide): Important and typically given urgently, but initial
immediate action is airway/oxygenation and positioning; once
oxygenation is initiated, IV diuretics are given promptly.
C (LMWH): May be indicated for DVT prophylaxis but not an
immediate priority in respiratory distress.
D (CXR): Diagnostic, but should not delay oxygenation support.
E (oral ACE inhibitor): Useful long-term but not immediate in acute
decompensation; also oral administration may be poor in distressed
patient.
Nursing priorities/teaching: Sit patient upright, apply oxygen/consider
CPAP, obtain IV access and give IV loop diuretic per order, monitor
oxygenation, urine output, vitals, and notify provider for further
management (vasodilators, inotropes if needed).
Question 3 — Pulmonary Embolism (PE)
A 45-year-old woman post-hysterectomy day 2 suddenly develops pleuritic
chest pain and shortness of breath. Pulse 120, BP 100/62, SpO₂ 88% on 2 L
NC. D-dimer elevated and CT pulmonary angiography confirms a large right
pulmonary embolus. Heparin infusion is started. Which nursing action is
most urgent?
A. Prepare for emergent thrombolytic therapy (alteplase).
B. Administer 81 mg aspirin daily.
C. Start warfarin oral therapy immediately and stop heparin once INR
therapeutic.
D. Place patient on strict bedrest and apply SCDs.
E. Encourage deep breathing and incentive spirometry.
Correct answer: A. Prepare for emergent thrombolytic therapy
(alteplase).
, 4|Page
Rationale:
A large PE with hemodynamic compromise (tachycardia, borderline BP,
hypoxemia) can be life-threatening; systemic thrombolysis is indicated for
massive PE with hemodynamic instability. The nurse’s role is to prepare the
patient (confirm contraindications, obtain consent if required, ensure large-
bore IV access, baseline labs including coagulation profile).
B (aspirin): Not appropriate for acute PE management.
C (warfarin): Transition to warfarin is long-term strategy; initial acute
management uses heparin and, if indicated, thrombolysis. Warfarin
initiation may occur but is secondary.
D (SCDs): Not appropriate — compression devices contraindicated in
diagnosed DVT/PE in acute setting for embolus management and
immobility may already be required.
E (incentive spirometry): Helpful postop but not priority in large PE.
Nursing priorities/teaching: Assess hemodynamic status continuously,
prepare for thrombolysis if ordered, check for bleeding contraindications,
coordinate with ICU/cardiothoracic if needed, educate family about
risks/benefits.
Question 4 — Sepsis / Septic Shock
A 56-year-old man with pneumonia becomes hypotensive (BP 82/50),
tachycardic 125, febrile 39.3°C, and lactate 4.2 mmol/L. Initial steps per
sepsis protocol have been started. Which action takes highest priority now?
A. Put the patient on broad-spectrum IV antibiotics immediately after blood
cultures.
B. Start norepinephrine infusion to maintain MAP ≥ 65 mmHg.
C. Begin aggressive IV crystalloid bolus (30 mL/kg).
D. Order a stat chest x-ray.
E. Administer IV corticosteroids.
Correct answer: C. Begin aggressive IV crystalloid bolus (30 mL/kg).
MEDICAL-SURGICAL NURSING III (NSG233) EXAM PACK – 100
NCLEX-STYLE QUESTIONS & ANSWERS [LATEST
2025/2026]100% CORRECT ALREADY GRADED A+
Question 1 — Acute Myocardial Infarction (STEMI)
A 62-year-old man arrives in the ED with crushing substernal chest pain
radiating to his left jaw and arm for 45 minutes. He is diaphoretic and
anxious. ECG shows ST-segment elevation in leads II, III, and aVF. Blood
pressure 110/68 mmHg, HR 92. Which action should the nurse perform
first?
A. Administer chewable aspirin 325 mg immediately.
B. Prepare the patient for immediate thrombolytic therapy.
C. Start a heparin infusion.
D. Give sublingual nitroglycerin.
E. Obtain blood for troponin and chemistries.
Correct answer: A. Administer chewable aspirin 325 mg immediately.
Rationale:
Aspirin (chewable) given immediately is the highest-priority, evidence-
based intervention in suspected acute MI — it inhibits platelet aggregation
and reduces mortality when given early. The patient is within the window
and not hypotensive. Chewable aspirin has faster absorption. While
reperfusion (PCI/thrombolysis) is critical, the first action at bedside is
aspirin.
B (thrombolytics): Indicated in STEMI when PCI unavailable within
guideline times, but not the first immediate action at bedside — also
contraindications must be assessed.
,2|Page
C (heparin): Anticoagulation is used in MI management but not before
aspirin; placement requires orders and IV access.
D (sublingual NTG): Good for pain and ischemia but nitroglycerin is
relatively contraindicated if inferior MI with right ventricle
involvement — leads II, III, aVF suggest inferior MI; give only after
assessing for RV infarct (check JVD, hypotension) and with physician
order.
E (labs): Important but not first — do concurrently when possible.
Nursing priorities/teaching: Give chewable aspirin immediately (unless
true allergy), call cath lab/notify cardiology for PCI, monitor vitals/ECG,
establish IV access, prepare for reperfusion. Educate patient about aspirin
purpose.
Question 2 — Acute Decompensated Heart Failure (Pulmonary Edema)
A 74-year-old woman with chronic heart failure is admitted with acute
dyspnea. She is anxious, has pink frothy sputum, RR 32, SpO₂ 85% on room
air, bilateral crackles to mid-lung fields, and JVD present. Which
intervention is highest priority?
A. Elevate head of bed and apply high-flow oxygen (nonrebreather or
CPAP).
B. Administer IV furosemide 40 mg push.
C. Give a subcutaneous dose of low-molecular-weight heparin.
D. Obtain a chest x-ray.
E. Start an oral ACE inhibitor.
Correct answer: A. Elevate head of bed and apply high-flow oxygen
(nonrebreather or CPAP).
Rationale:
This patient demonstrates acute pulmonary edema with hypoxemia.
Immediate airway/oxygenation support and decreasing preload (upright
position) take priority to improve oxygenation and reduce work of breathing.
,3|Page
CPAP or BiPAP can improve oxygenation and reduce preload/afterload
quickly.
B (IV furosemide): Important and typically given urgently, but initial
immediate action is airway/oxygenation and positioning; once
oxygenation is initiated, IV diuretics are given promptly.
C (LMWH): May be indicated for DVT prophylaxis but not an
immediate priority in respiratory distress.
D (CXR): Diagnostic, but should not delay oxygenation support.
E (oral ACE inhibitor): Useful long-term but not immediate in acute
decompensation; also oral administration may be poor in distressed
patient.
Nursing priorities/teaching: Sit patient upright, apply oxygen/consider
CPAP, obtain IV access and give IV loop diuretic per order, monitor
oxygenation, urine output, vitals, and notify provider for further
management (vasodilators, inotropes if needed).
Question 3 — Pulmonary Embolism (PE)
A 45-year-old woman post-hysterectomy day 2 suddenly develops pleuritic
chest pain and shortness of breath. Pulse 120, BP 100/62, SpO₂ 88% on 2 L
NC. D-dimer elevated and CT pulmonary angiography confirms a large right
pulmonary embolus. Heparin infusion is started. Which nursing action is
most urgent?
A. Prepare for emergent thrombolytic therapy (alteplase).
B. Administer 81 mg aspirin daily.
C. Start warfarin oral therapy immediately and stop heparin once INR
therapeutic.
D. Place patient on strict bedrest and apply SCDs.
E. Encourage deep breathing and incentive spirometry.
Correct answer: A. Prepare for emergent thrombolytic therapy
(alteplase).
, 4|Page
Rationale:
A large PE with hemodynamic compromise (tachycardia, borderline BP,
hypoxemia) can be life-threatening; systemic thrombolysis is indicated for
massive PE with hemodynamic instability. The nurse’s role is to prepare the
patient (confirm contraindications, obtain consent if required, ensure large-
bore IV access, baseline labs including coagulation profile).
B (aspirin): Not appropriate for acute PE management.
C (warfarin): Transition to warfarin is long-term strategy; initial acute
management uses heparin and, if indicated, thrombolysis. Warfarin
initiation may occur but is secondary.
D (SCDs): Not appropriate — compression devices contraindicated in
diagnosed DVT/PE in acute setting for embolus management and
immobility may already be required.
E (incentive spirometry): Helpful postop but not priority in large PE.
Nursing priorities/teaching: Assess hemodynamic status continuously,
prepare for thrombolysis if ordered, check for bleeding contraindications,
coordinate with ICU/cardiothoracic if needed, educate family about
risks/benefits.
Question 4 — Sepsis / Septic Shock
A 56-year-old man with pneumonia becomes hypotensive (BP 82/50),
tachycardic 125, febrile 39.3°C, and lactate 4.2 mmol/L. Initial steps per
sepsis protocol have been started. Which action takes highest priority now?
A. Put the patient on broad-spectrum IV antibiotics immediately after blood
cultures.
B. Start norepinephrine infusion to maintain MAP ≥ 65 mmHg.
C. Begin aggressive IV crystalloid bolus (30 mL/kg).
D. Order a stat chest x-ray.
E. Administer IV corticosteroids.
Correct answer: C. Begin aggressive IV crystalloid bolus (30 mL/kg).
