Medical-Surgical Nursing I Practice Exam with Explanations

Clinical judgment grows through steady, case-based practice. This set mirrors the choices nurses make on a busy general unit—recognizing early deterioration, selecting the safest next step, coordinating with the team, and teaching patients in plain, useful language. The focus is on fundamentals that don’t age: airway and bleeding checks after surgery, thoughtful fluid and electrolyte decisions, early recognition of cardiac rhythms and respiratory changes, and education patients can actually follow. If you’re preparing for a Med Surg 1 practice exam, these scenarios match real floor decisions.

Use it alongside Medical-Surgical Nursing I to strengthen habits that anchor safe care: read vital signs in context, prioritize with ABCs, and turn rationales into brief action sequences you could follow at 03:00 just as reliably as at noon. Each scenario favors reasoning over recall, nudges you to think two steps ahead, and shows how small nursing actions—proper site marking, a timely call about potassium, a reminder to rinse after an inhaled steroid—prevent complications and keep patients safer. Consider this your practical Medical-Surgical Nursing I test bank for routine shifts.

About This Exam

Master the foundations of Medical-Surgical Nursing I with course-level, unit-style practice. This pack is built for ADN/BSN students taking Med-Surg I (course exam, not licensure). Questions mirror the way colleges test during quizzes, midterms, and finals—single-best answers, short case vignettes, and selective SATA where schools commonly use them. It’s ideal if you’re facing a unit exam Med-Surg 1 this term.

Every item includes a clear, step-by-step rationale that ties pathophysiology to assessment and safe nursing interventions, so you learn why the correct option is right (and why distractors are wrong). Content aligns with typical Med-Surg I syllabi: peri-operative basics, fluids & electrolytes, ABG fundamentals, respiratory (pneumonia/TB), cardiac foundations (HTN/angina), diabetes day-to-day care, GI non-critical (GERD/PUD/cholecystitis), renal/urinary (UTI/BPH), integumentary & wound healing, mobility & safety, and routine delegation.

Designed for focused study sessions, you’ll get two full-length course exams plus a targeted question bank for quick drills before class or clinical. Use it to check readiness, remediate weak spots fast, and walk into your next unit exam confident and prepared.

What This Exam Topics Covers

You’ll practice across the full Med-Surg I map, carefully aligned to the questions and rationales above:

Perioperative Basics

• Informed consent (capacity, timing, who obtains it), site marking, and the safety time-out
• Pre-op teaching: fasting rules (clear liquids vs solids), medication decisions (e.g., continue beta-blockers), skin prep (CHG), and herbal/OTC risks
• Post-op priorities: airway first, bleeding/hematoma recognition, early mobility, incentive spirometry, and pain plans
• Drains and dressings: what’s expected versus escalation cues; documentation that actually helps clinicians

Fluids, Electrolytes & Acid–Base

• Potassium disturbances: hypokalemia (U waves, ileus) vs hyperkalemia (peaked T waves, immediate calcium)
• Sodium disorders: SIADH vs DI patterns; safe correction principles
• Calcium & magnesium basics, albumin-corrected calcium, refeeding syndrome awareness
• ABG interpretation: identifying primary disorders, Winter’s formula, and mixed acid–base patterns you’ll really encounter

Pain & Comfort

• Multimodal analgesia (acetaminophen, NSAIDs when safe, regional techniques, non-pharm)
• PCA safety (“no proxy”), sedation/respiratory monitoring, naloxone indications
• Opioid rotation, histamine-mediated pruritus vs true allergy, OSA-aware pain plans

Mobility & Musculoskeletal

• Hip precautions (posterior approach), safe transfers, and assistive device fit
• Traction essentials (weights hang freely, pin-site care), fracture red flags (compartment syndrome, fat embolism)
• Osteoporosis prevention and joint protection strategies that reduce falls and readmissions

Integumentary (Non-ICU)

• Pressure injury prevention (off-loading, moisture management vs MASD)
• Wound healing, staples/sutures removal sequence, negative pressure wound therapy basics
• Minor burn first aid, shingles precautions, diabetic foot protection and off-loading

Cardiac Foundations

• Chronic hypertension management and patient-centered sodium coaching
• Stable angina vs ACS, nitroglycerin rules (PDE-5 timing, storage), when to call EMS
• Murmur recognition (AS, MVP), common telemetry findings (PVCs, first-degree block), atrial fibrillation stroke risk and anticoagulation basics

Respiratory Foundations

• Pneumonia triage and oxygenation priorities; sepsis screening cues
• TB precautions (airborne/negative pressure), asthma action plans (peak flow zones)
• Incentive spirometry teaching that works, chest tube troubleshooting (air leaks), aspiration prevention after stroke

GI (Non-Critical)

• GERD PPI timing, H. pylori eradication and follow-up, diverticulitis diet staging
• Cholecystitis triggers and pre-op teaching
• Upper GI bleed resuscitation steps you must know cold

Renal/Urinary

• UTI vs pyelonephritis (who can go home vs who can’t), obstructed infection red flags
• Nephrolithiasis teaching (hydration, oxalate, normal dietary calcium), urine straining
• BPH: meds to avoid, catheter choices (Coude), and post-op urinary retention pathways
• Dialysis access protection (no BP/IV/labs on fistula arm)

Endocrine Foundations

• Hypo- vs hyperthyroidism routine care; storm/myxedema early recognition
• Diabetes day-to-day: sick-day rules, SGLT2 holds, nocturnal hypo prevention after exercise
• Cushing/Addison basics; salt and stress dosing in adrenal insufficiency

Patient Education & Health Promotion

• Vaccination essentials (Tdap, influenza, zoster; indications by age/risk)
• Heart-healthy plate and realistic sodium swaps patients can adopt

Prioritization & Delegation

• “Worst-first” triage using airway/breathing/circulation and neuro changes
• Who can do what: RN vs LPN vs UAP, and the wording that makes delegation safe and clear

Who Can Take This Exam

• Pre-licensure nursing students in Med-Surg I or fundamentals-to-Med-Surg bridge
• Internationally educated nurses preparing to refresh U.S. ward practices
• Re-entry or transition nurses moving back into acute care
• Allied health learners who want to understand nursing decision-making on med-surg units

What This Exam Is Useful For

• Midterm or final prep in medical surgical exam 1
• Unit competency review before a med-surg clinical rotation
• Fast remediation: identify weak systems, then re-study with purpose
• Interview readiness: you’ll handle common “what would you do next?” scenarios with confidence

How This Exam Is Structured

• Application-level case stems (no trickery, no fluff)
• Clear answer keys with teaching-quality rationales that connect signs, labs, and policies
• Topic balance that feels like a real shift: you’ll bounce from chest pain to drains to electrolytes—just like the unit

Study Tips: How to Pass Med-Surg I

• Think in bundles, not single steps.
  Example: suspected upper GI bleed isn’t “start a PPI”—it’s large-bore IVs, labs + type & screen, resuscitation, NPO, PPI, and GI consult. Train your brain to execute the safe sequence.
• Anchor patterns for high-yield disorders.
  Hyperkalemia → IV calcium first if ECG changes; then shift and remove K⁺.
  SIADH → low serum osmolality + high urine osmolality, euvolemic exam → fluid restriction and slow correction.
  Compartment syndrome → pain out of proportion, pain with passive stretch → urgent decompression.
• Memorize pre-op and post-op rules you’ll use daily.
  Clear liquids up to 2 hours pre-induction (per policy). Continue beta-blockers; be cautious with ACEi/ARBs. Posterior hip: no flexion >90°, no adduction, no internal rotation.
• Practice delegation wording.
  Tell a UAP exactly what to do and what to report (e.g., “Apply SCDs now and report if the skin reddens or if the patient refuses”). Keep assessment, teaching, and IV titration with the RN.
• Prioritize by threat to life or limb.
  New airway sounds, rapidly saturating dressings, severe electrolyte derangements with ECG changes, and neuro decline beat routine tasks every time. If two situations feel urgent, use ABCs and trend data (vital signs, drain output, neuro checks).
• Turn rationales into flash-algorithms.
  Re-write explanations as 3–5-step micro-protocols you can recall under pressure.
• Teach-back to a peer.
  If you can quickly explain why nitrates and PDE-5s can’t mix—or why airborne not droplet is needed for TB—you’re ready.
• Simulate a shift.
  Do mixed blocks of questions—no topic clustering—to train cognitive switching.
• Close the loop with patient education.
  Most safe answers end with education: how to use IS, how to store nitro, how to weigh daily, or how to rotate insulin sites.

This Medical-Surgical Nursing I Practice Exam concentrates on what truly moves patient outcomes: timely recognition, safe bundles, and clear communication. If you’re preparing for medical surgical exam 1, use these cases to sharpen your instincts, not just your memory. Work through the rationales, convert them into small, repeatable algorithms, and you’ll walk into class—and clinical—ready to think and act like a med-surg nurse.

Medical-Surgical Nursing I Sample Questions and Answers

1) Perioperative: Informed consent & time-out

A patient is on the stretcher outside the OR. The surgeon has left the unit. During the time-out, the circulating nurse notices the consent form lists a left inguinal hernia repair, but the patient and wristband indicate a right inguinal hernia. What is the nurse’s best action?
A. Continue because consent is present and anesthesia is ready
B. Cross out “left” and write “right,” then initial it
C. Stop the process and notify the surgeon to verify and correct consent
D. Ask the patient to verbally confirm “right side” and proceed
Answer: C
Rationale: The standardized time-out is a universal safety step to prevent wrong-site, wrong-procedure, wrong-patient surgery. Any discrepancy requires an immediate stop until it is fully resolved by the provider performing the procedure. Nurses cannot alter the legal consent; only the practitioner obtains/clarifies consent for the correct procedure and site. Proceeding based on verbal confirmation without correcting documentation is unsafe and violates policy and The Joint Commission expectations. Patient safety overrides workflow pressure.

2) Perioperative: Pre-op teaching (NPO & meds)

A morning surgery patient asks which home meds to take with a sip of water. Which combo is most appropriate pre-op?
A. Metformin and lisinopril
B. Metoprolol and levothyroxine
C. Apixaban and hydrochlorothiazide
D. Empagliflozin and aspirin (325 mg)
Answer: B
Rationale: Typical pre-op guidance: continue essential meds like beta-blockers (avoid rebound tachycardia/ischemia) and levothyroxine with a small sip of water, while usually holding metformin/SGLT2 inhibitors (lactic acidosis/euglycemic DKA risks), ACEi/ARBs per anesthesia plan (intra-op hypotension), and anticoagulants/antiplatelets as directed to reduce bleeding (low-dose ASA may be continued for some cardiac indications; 325 mg is often held). Always follow individualized orders, but B aligns with common safety practice and NPO rules.

3) Perioperative: PACU priorities (airway, bleeding, IS, DVT prophylaxis, drains)

Immediately post-op, which order of assessments/interventions is best?
A. Pain, drain output, incentive spirometry, dressing
B. Airway/breathing, circulation/bleeding, neuro, drains/dressings, early DVT prevention
C. Temperature, pain, drains, neuro, IS
D. Dressing check, pain, ambulation, airway
Answer: B
Rationale: Post-anesthesia priorities follow ABCs first: ensure a patent airway, adequate ventilation, and oxygenation; then assess circulation (HR, BP, perfusion) and surgical site bleeding. Next, evaluate neuro (LOC, orientation), then check drains (e.g., JP/Hemovac—secure, patent, record color/amount), and dressings. Initiate pulmonary hygiene (incentive spirometry) and VTE prophylaxis based on orders (early ambulation, SCDs, pharmacologic agents). Pain management fits after stabilization. This sequence targets life-threats, bleeding, and post-op complications early.

4) Fluids & Electrolytes: Hypokalemia ECG

Which ECG change is most consistent with hypokalemia?
A. Peaked T waves and widened QRS
B. Flattened or inverted T waves with prominent U waves
C. Prolonged PR with delta wave
D. ST-segment elevation
Answer: B
Rationale: Low K⁺ (<3.5 mEq/L) often produces T-wave flattening/inversion and U waves (best seen in precordial leads). Patients may have ventricular ectopy and risk for dysrhythmias, especially if on digoxin. Hyperkalemia produces peaked T waves, prolonged PR, and QRS widening. Delta wave suggests WPW. ST elevation reflects acute ischemia. For hypokalemia, monitor rhythm, replace potassium carefully (IV via pump with EKG monitoring if needed), correct Mg²⁺ if low, and address causes (diuretics, GI losses).

5) Fluids & Electrolytes: Hyperkalemia treatment

A patient with CKD has K⁺ 6.8 mEq/L and ECG shows peaked T waves. What is the first priority medication?
A. IV furosemide
B. IV calcium gluconate
C. Oral sodium polystyrene
D. IV insulin without dextrose
Answer: B
Rationale: In unstable or ECG-changed hyperkalemia, stabilize the myocardium first with IV calcium (gluconate or chloride per line type) to reduce risk of malignant arrhythmias. Then shift K⁺ intracellularly with insulin + dextrose, consider beta-agonists, and remove K⁺ from the body (loop diuretics if kidneys function, potassium binders, dialysis if severe/CKD). Insulin must be paired with dextrose unless hyperglycemic. Sodium polystyrene works slowly. Continuous ECG and frequent K⁺ checks are essential.

6) Fluids & Electrolytes: Hyponatremia

A runner is admitted after a marathon with confusion and Na⁺ 120 mEq/L. Which plan is safest?
A. Rapid correction with 3% saline to normal within 6 hours
B. Careful correction with hypertonic saline if symptomatic, limiting rise to ≈ 4–6 mEq/L in first 24 h
C. Free water and desmopressin
D. Large IV fluid boluses of hypotonic saline
Answer: B
Rationale: Symptomatic acute hyponatremia needs hypertonic saline but over-rapid correction risks osmotic demyelination. Standard targets limit increases to about 4–6 mEq/L in 24 hours (institutional protocols may vary). Monitor neuro status, serum Na⁺ trends, and avoid hypotonic fluids. Identify cause (excess free water/SIADH). Desmopressin is used to prevent overcorrection in some protocols, not to worsen hyponatremia. Controlled, frequent reassessment is crucial.

7) Fluids & Electrolytes: Hypocalcemia

Which finding suggests hypocalcemia requiring prompt evaluation?
A. Bone pain and constipation
B. Positive Trousseau sign with perioral tingling
C. Polyuria and kidney stones
D. Facial flushing and pruritus after opioids
Answer: B
Rationale: Hypocalcemia (often after thyroid/neck surgery, hypoparathyroidism, or vitamin D issues) manifests with neuromuscular excitability: numbness/tingling, muscle cramps, Trousseau (carpal spasm with BP cuff) and Chvostek (facial twitch). Severe cases risk laryngospasm and seizures. Hypercalcemia features stones, bones, groans, psychiatric overtones (polyuria, stones, constipation). Manage with oral/IV calcium, vitamin D, and treat causes. Place on seizure precautions if severe; monitor airway if stridor/spasm suspected.

8) Acid–Base: ABG basics

ABG: pH 7.30, PaCO₂ 55 mmHg, HCO₃⁻ 26 mEq/L. What is the primary imbalance?
A. Metabolic acidosis
B. Respiratory acidosis (uncompensated)
C. Metabolic alkalosis with partial compensation
D. Respiratory alkalosis
Answer: B
Rationale: Low pH (<7.35) = acidemia. Elevated PaCO₂ (>45) with normal HCO₃⁻ indicates primary respiratory acidosis (think hypoventilation: COPD exacerbation, CNS depression, poor chest expansion). Compensation by kidneys raises HCO₃⁻ over time; here it’s normal → uncompensated. Interventions address ventilation: airway patency, bronchodilators, treat underlying cause, cautious oxygen in CO₂ retainers per protocol, and consider noninvasive ventilation if appropriate with close monitoring.

9) Pain & Comfort: Multimodal analgesia

A post-op colectomy patient has orders for acetaminophen, ketorolac, and low-dose hydromorphone PRN. Why is this approach preferred?
A. It’s cheaper
B. Different mechanisms reduce pain more effectively while lowering opioid dose and side effects
C. It lets the nurse give more opioids
D. It prevents all nausea
Answer: B
Rationale: Multimodal analgesia (acetaminophen + NSAID ± regional + small opioid) targets pain pathways at several points, improving analgesia and reducing opioid requirements. This often decreases sedation, ileus, respiratory depression, PONV, and constipation—key ERAS goals. It doesn’t eliminate all nausea and isn’t about giving “more opioids.” Nurses still assess pain, function, and side effects, using non-pharm measures (ice/heat, splinting, repositioning, breathing/relaxation) to enhance comfort and mobility.

10) Pain: PCA safety

Which statement about PCA is correct?
A. Family may press the button when the patient is sleeping
B. Only the patient may press the button; monitor sedation/respirations and have naloxone available
C. Basal infusions eliminate the need for monitoring
D. Capnography isn’t useful
Answer: B
Rationale: No proxy dosing—only the patient activates PCA to match need and consciousness. Nurses assess pain, level of sedation, RR, and quality of breathing; monitor for oversedation, especially with opioids or concurrent CNS depressants. Capnography or continuous pulse-ox may be used per policy for early detection of hypoventilation. A basal rate increases risk in opioid-naïve patients and demands closer monitoring, not less. Keep naloxone available and educate patient/family about safe use.

11) Mobility/MSK: Posterior hip precautions

A day-2 post-op total hip (posterior approach) asks about movement. Which teaching is correct?
A. Cross your legs to keep the hip aligned
B. Sit in low, soft chairs
C. Avoid hip flexion >90°, no internal rotation or adduction; use an abduction pillow
D. Pivot on the operative leg
Answer: C
Rationale: Posterior hip approach risks posterior dislocation. Teach: no hip flexion >90°, avoid adduction (don’t cross legs), and avoid internal rotation. Use a raised toilet seat, abduction pillow between legs, and firm chairs with armrests. Instruct on log-rolling and avoiding twisting/pivoting on the operative leg. Early PT-guided ambulation prevents DVT and supports function. Cue patients to keep toes pointed forward/out slightly and maintain hip precautions until cleared.

12) Mobility/MSK: Traction care

A patient is on skeletal traction for a femur fracture. What nursing action is essential?
A. Place weights on the bed when turning
B. Loosen ropes if the patient reports pain
C. Ensure weights hang freely; maintain alignment; perform frequent neurovascular checks
D. Remove the boot to massage the heel
Answer: C
Rationale: In traction, weights must hang freely to deliver constant force, and the line of pull/alignment must be maintained. Frequent neurovascular assessment (pain, pallor, pulses, paresthesia, paralysis, poikilothermia; cap refill; compartments) detects ischemia and compartment syndrome early. Never add/remove/lean weights on bed. Do not loosen traction independently. Provide skin care and heel off-loading without removing prescribed devices. Report unrelieved pain or neuro changes promptly.

13) Integumentary: Wound healing stages

Which sequence reflects normal wound healing?
A. Proliferation → Inflammation → Maturation
B. Hemostasis/Inflammation → Proliferation/Granulation → Maturation/Remodeling
C. Inflammation → Maturation → Hemostasis
D. Granulation → Inflammation → Epithelialization
Answer: B
Rationale: Wound healing begins with hemostasis and inflammation (clotting, debris removal), progresses to proliferation/granulation (angiogenesis, fibroblasts, collagen, epithelialization), and ends with maturation/remodeling (collagen reorganization, increased tensile strength). Support healing with adequate protein, calories, vitamin C, zinc, glycemic control, pressure redistribution, and moisture-balanced dressings. Monitor for infection (erythema, warmth, purulent drainage, pain, odor) and dehiscence risk (splinting, abdominal binders, avoiding strain).

14) Integumentary: Basic burn first-aid

A cook sustains a partial-thickness hand burn from hot oil at home 10 minutes ago. What first-aid is best?
A. Apply ice directly for 20 minutes
B. Cool with cool (not cold) running water for ~20 minutes, remove rings/jewelry, cover with clean non-adhesive dressing
C. Break blisters to drain fluid
D. Apply butter to seal the wound
Answer: B
Rationale: Immediate cool running water reduces burn depth; avoid ice (frostbite risk) and butter/ointments initially (traps heat/contaminates). Remove constricting items (rings/watches) early as swelling develops. Cover with a clean, dry dressing and seek evaluation for TBSA, depth, tetanus status, and pain control. For extensive or circumferential burns, suspect airway compromise or compartment syndrome and follow emergency protocols. Maintain hand elevation to reduce edema.

15) Cardiac: Chronic HTN management (and heart-healthy diet)

A patient with stage-2 HTN and no compelling comorbidities asks about first-line therapy. Which plan is most appropriate?
A. Clonidine PRN and high-protein diet
B. Start a thiazide-type diuretic, ACEi/ARB, or CCB plus lifestyle: DASH diet, Na⁺ <1.5–2 g/day, weight loss, exercise, limit alcohol
C. Beta-blocker monotherapy for all patients
D. Herbal supplements only
Answer: B
Rationale: 2025 practice favors thiazide-type diuretics, ACEi/ARB, or CCB as core first-line agents (two drugs often for stage-2). Lifestyle is foundational: DASH pattern (fruits/veg/low-fat dairy/whole grains), sodium restriction, weight reduction, physical activity (≥150 min/wk moderate), limit alcohol, and stop smoking. Beta-blockers aren’t universal first-line unless specific indications (e.g., CAD/HFrEF). Reinforce home BP monitoring, adherence, and periodic labs (K⁺/creatinine with RAAS blockers, electrolytes with diuretics).

16) Cardiac: Stable angina vs ACS

A patient reports chest pressure with stairs, relieved by rest and nitroglycerin, unchanged for months. Which is most consistent?
A. NSTEMI
B. Stable angina
C. Unstable angina
D. Prinzmetal (variant) angina
Answer: B
Rationale: Stable angina is predictable, exertional, and relieved by rest or nitro with stable pattern. Unstable angina involves new, worsening, or rest pain not fully relieved by nitro and signals ACS. NSTEMI/STEMI include biomarker elevation and/or ST changes with ischemic symptoms. Variant angina occurs at rest with transient ST elevation due to coronary vasospasm. Teach nitro use (1 tab q5 min ×3 then emergency call), risk reduction, and follow-up.

17) Cardiac: Heart sounds/murmurs basics

Which murmur description most suggests aortic stenosis?
A. Diastolic rumble at apex with opening snap
B. Systolic crescendo–decrescendo at right second ICS radiating to carotids
C. Holosystolic at apex radiating to axilla
D. High-pitched blowing diastolic at left sternal border
Answer: B
Rationale: Aortic stenosis produces a harsh systolic ejection murmur at the right 2nd intercostal space with carotid radiation; may have soft/absent S2. Mitral stenosis is a diastolic rumble with opening snap. Mitral regurgitation is holosystolic at apex to axilla. Aortic regurgitation is diastolic blowing at LSB. Correlate findings with symptoms (syncope, angina, dyspnea), pulses, and echo results. Avoid aggressive afterload reduction in severe AS without guidance.

18) Cardiac: Common ECG rhythm

An elderly patient has an irregularly irregular rhythm with no distinct P waves and variable R-R intervals. What is the rhythm?
A. Atrial flutter
B. Atrial fibrillation
C. Ventricular tachycardia
D. Sinus arrhythmia
Answer: B
Rationale: A-fib shows chaotic atrial activity with no discrete P waves and an irregularly irregular ventricular response. Risks include thromboembolism and rate-related symptoms. Initial priorities: rate control (β-blocker/CCB), anticoagulation evaluation (CHA₂DS₂-VASc), and symptom management; rhythm control is individualized. Flutter has saw-tooth F waves with regular conduction. VT is wide-complex tachycardia (hemodynamic concern). Sinus arrhythmia varies with respiration, usually benign.

19) Respiratory: Pneumonia care & IS

Which teaching supports recovery from community-acquired pneumonia?
A. Bedrest until the cough stops
B. Frequent incentive spirometry, early ambulation, hydration, and completion of the antibiotic course
C. Stop fluids to reduce secretions
D. Cough suppression at all times
Answer: B
Rationale: For pneumonia, encourage pulmonary hygiene (IS every 1–2 hours while awake), early ambulation and position changes, adequate fluids to thin secretions, and strict antibiotic adherence. Antitussives may be used selectively for rest but coughing/DB&C helps clearance. Monitor for worsening dyspnea, fever, pleuritic pain, or hypoxemia. Vaccination (influenza, pneumococcal as indicated) reduces recurrence risk; smoking cessation is strongly advised.

20) Respiratory: TB precautions

A patient with suspected pulmonary TB is arriving from the ED. What is the priority infection-control action?
A. Standard precautions only
B. Droplet precautions with surgical mask
C. Airborne precautions: negative-pressure room; fit-tested N95 for staff/visitors per policy
D. Contact precautions only
Answer: C
Rationale: Pulmonary TB requires airborne precautions: negative-pressure room, door closed, and N95 or higher-level respirators for staff (visitors per facility policy). A surgical mask is insufficient for airborne pathogens. Continue until active TB is ruled out or patient is noninfectious per public health guidance. Teach cough etiquette, ensure medication adherence if diagnosed, and coordinate with infection control and public health services.

21) Adult vaccine schedule (health promotion)

Which adult (≥19 years) vaccine plan is most accurate for a generally healthy 45-year-old with uncertain records?
A. Annual influenza; 1-time Tdap then Td/Tdap booster every 10 years; complete COVID-19 series/boosters per current guidance; zoster starting at 50; pneumococcal at 65 unless risk factors
B. Zoster annually starting at 40
C. Pneumococcal every 2 years regardless of age
D. Skip Tdap if no infants at home
Answer: A
Rationale: Adult schedules include yearly influenza, Tdap once (then Td/Tdap q10y), and age/risk-based vaccines: zoster (recombinant series beginning at 50), pneumococcal at 65 (earlier for certain conditions), plus COVID-19 series/boosters per current national guidance. Other vaccines (HPV catch-up, hepatitis A/B, MMR, varicella) depend on age, risk, and documentation. Nurses assess history, risks, and provide VIS education and documentation.

22) GI: Peptic ulcer disease (H. pylori)

A patient with confirmed H. pylori PUD asks about treatment. The best explanation is:
A. Antacids alone
B. Combination therapy with antibiotics plus a PPI; avoid NSAIDs and complete the full regimen
C. Long-term steroids
D. Only diet changes
Answer: B
Rationale: H. pylori ulcers require eradication therapy (e.g., bismuth-based or non-bismuth regimens) plus PPI to heal mucosa. Adherence to the full course is crucial to prevent resistance/recurrence. Avoid NSAIDs, stop smoking, limit alcohol, and report alarm features (GI bleeding, weight loss). For NSAID-related ulcers, stop NSAID and add PPI or misoprostol if NSAIDs must continue. Educate on recognizing melena/hematemesis and when to seek urgent care.

23) GI: IBD vs IBS

Which finding best differentiates IBD (Crohn’s/UC) from IBS?
A. Abdominal pain with bowel habit change
B. Pain relieved after defecation
C. Objective inflammation (fever, blood in stool, ↑CRP/ESR, anemia, weight loss)
D. Bloating and gas
Answer: C
Rationale: IBD features inflammation and mucosal damage—hematochezia, systemic signs (fever, weight loss), lab inflammation, anemia, and endoscopic changes. IBS is a functional disorder with abdominal pain related to defecation and stool changes without tissue injury or systemic inflammation. IBD management may include aminosalicylates, steroids, immunomodulators/biologics, nutrition support, and cancer surveillance. IBS care emphasizes diet (low-FODMAP for some), stress reduction, and symptom-targeted meds.

24) GI: Ostomy basics

A new ileostomy patient asks about output and hydration. Which teaching is best?
A. Expect formed stool; dehydration is rare
B. Output is typically liquid to paste; increase fluids/electrolytes; monitor for high output and signs of dehydration
C. Use laxatives if no stool in 6 hours
D. Limit salt intake strictly
Answer: B
Rationale: Ileostomy effluent is liquid/semi-liquid, rich in fluid and electrolytes; patients risk dehydration and hyponatremia. Encourage adequate fluids, consider oral rehydration solutions, and recognize high-output stoma signs (very large volume, dizziness, dark urine). Teach pouching, skin protection, diet progression (introduce gas/odor-producing foods cautiously), and when to contact the provider (no output, severe cramps, persistent skin breakdown). Chew foods well to reduce blockage risk.

25) Renal/Urinary: UTI vs pyelonephritis

Which presentation most suggests acute pyelonephritis rather than uncomplicated cystitis?
A. Dysuria and frequency only
B. Fever, chills, flank pain with CVA tenderness, and nausea
C. Hematuria without fever
D. Suprapubic discomfort only
Answer: B
Rationale: Pyelonephritis (upper UTI) commonly presents with fever, chills, flank pain, CVA tenderness, and systemic symptoms (N/V). Cystitis involves dysuria, urgency, frequency, and suprapubic pain without systemic illness. Management differs: pyelo often needs systemic antibiotics, sometimes IV initially, hydration, and close monitoring; cystitis can be managed with short-course oral agents. Teach prevention: hydration, urinating pre/post sex, not delaying voiding, and correct perineal hygiene.

26) Renal/Urinary: Nephrolithiasis teaching

Which discharge instruction best helps prevent kidney stones recurrence?
A. Increase fluid intake to target ≥2–2.5 L urine/day; dietary changes based on stone type
B. Restrict all calcium strictly
C. Avoid exercise
D. Take daily baking soda
Answer: A
Rationale: Universal prevention is high fluid intake to produce ≥2–2.5 L urine/day. Diet is tailored: adequate dietary calcium (not extreme restriction) binds oxalate in gut; limit sodium and oxalate (spinach, nuts), moderate animal protein, and consider citrate (e.g., lemon water) for hypocitraturia. For uric acid stones, reduce purines and consider urine alkalinization. Encourage activity and weight management; strain urine if advised to capture stones for analysis.

27) Renal/Urinary: BPH routine care

A patient with BPH reports nocturia and weak stream. Which initial management is typical?
A. Immediate TURP
B. Alpha-1 blocker (e.g., tamsulosin) with lifestyle strategies; evaluate meds that worsen symptoms (anticholinergics/decongestants)
C. Long-term indwelling catheter
D. High-dose loop diuretic at bedtime
Answer: B
Rationale: First-line BPH therapy is an alpha-1 blocker to relax prostatic smooth muscle; 5-alpha-reductase inhibitors (finasteride) shrink prostate over months if indicated. Teach timed voiding, fluid moderation in evening, and avoiding anticholinergics and sympathomimetics that worsen retention. Monitor for hypotension/dizziness with tamsulosin. TURP or minimally invasive procedures are for refractory or complicated cases (retention, recurrent infections, renal impact).

28) Endocrine: Hypothyroidism vs hyperthyroidism routine care

Which statement is accurate teaching?
A. Levothyroxine is taken with meals for better absorption
B. Take levothyroxine on an empty stomach in the morning; report palpitations or insomnia
C. Stop methimazole once symptoms improve
D. Beta-blockers cure hyperthyroidism
Answer: B
Rationale: Levothyroxine is best absorbed on an empty stomach (30–60 min before breakfast) and away from calcium/iron. Watch for over-replacement signs (palpitations, tremor, insomnia). Hyperthyroidism may be treated with antithyroid drugs (methimazole), radioiodine, or surgery; beta-blockers control symptoms (tachycardia/tremor) but are not curative. Adherence and periodic TSH checks guide dosing. Teach medication interactions and the need to avoid abrupt changes without provider input.

29) Endocrine: Cushing vs Addison baseline

Which finding aligns more with Addison disease than Cushing syndrome?
A. Central obesity, purple striae, hyperglycemia
B. Hyperpigmentation, weight loss, hypotension, hyponatremia, hyperkalemia
C. Moon face and proximal muscle weakness
D. Recurrent infections and osteoporosis
Answer: B
Rationale: Addison (primary adrenal insufficiency) features low cortisol/aldosterone → hypotension, hyponatremia, hyperkalemia, weight loss, fatigue, and hyperpigmentation from ↑ACTH. Cushing (excess cortisol) shows central adiposity, moon face, striae, hyperglycemia, muscle weakness, mood changes, infections, and bone loss. Stress dosing of steroids is essential in adrenal insufficiency; teach to carry medical alert ID, never stop steroids abruptly, and recognize adrenal crisis triggers (illness, surgery).

30) Patient education: Diabetes sick-day rules

Which instruction is best for type 2 diabetes during acute illness with reduced intake?
A. Stop all diabetes meds until you’re eating normally
B. Check glucose more often, maintain hydration with carbs/electrolytes, continue basal insulin or usual meds unless told otherwise, and seek help for persistent vomiting or high readings
C. Avoid carbohydrates entirely
D. Skip fluids to reduce urination
Answer: B
Rationale: Sick-day care aims to prevent dehydration and ketosis/hyperglycemia. Encourage frequent glucose checks, keep fluids with carbohydrates/electrolytes, and continue basal insulin (or most oral meds) unless contraindicated by provider; adjust correction doses per plan. Seek care for persistent vomiting, inability to keep fluids down, very high glucose, ketones (for those instructed), or signs of DKA/HHS. Hold metformin if dehydrated or with contrast/procedures per guidance.

Case Vignettes

1) Perioperative — consent/time-out

A 64-year-old scheduled for left TKA signs consent yesterday. In pre-op you notice the site mark on the right knee and the consent reads “total knee arthroplasty” without laterality. What’s your immediate action?
Answer: Stop workflow and call a formal time-out/verification → correct consent and site mark before any premeds.
Why it’s right: Wrong-site surgery prevention requires halting the line until patient, procedure, and laterality are reconciled and re-documented with the awake patient and surgeon.

2) Perioperative — NPO & meds

A 72-year-old with CAD on metoprolol and lisinopril is NPO for 0730 anesthesia. Which med timing is safest?
Answer: Continue beta-blocker with a sip of water; generally hold ACEi/ARB the morning of surgery unless directed otherwise.
Why it’s right: Prevents rebound ischemia/tachycardia and avoids refractory intra-op hypotension seen with ACEi/ARB.

3) Perioperative — PACU airway/bleeding

POD0 thyroidectomy patient reports neck tightness and trouble swallowing; you see dressing bleeding and a firm anterior neck. Priority?
Answer: Airway first—raise HOB, O₂, call surgeon/anesthesia emergently; prepare to release sutures per protocol.
Why it’s right: Expanding hematoma → airway obstruction. Airway maneuvers precede routine vitals or analgesics.

4) Fluids/Electrolytes — hypokalemia ECG

A post-GI loss patient has K⁺ 2.9, weakness, and ECG with U waves. Best initial nursing action?
Answer: Put on telemetry, replete K⁺ (and check Mg²⁺) per protocol, re-draw BMP.
Why it’s right: Ventricular ectopy risk rises when K⁺<3.0, and repletion fails unless Mg²⁺ is corrected.

5) Fluids/Electrolytes — hyperkalemia treatment

A CKD patient has K⁺ 6.8 with peaked T waves. Which drug first?
Answer: IV calcium gluconate to stabilize myocardium, then insulin/dextrose and definitive K⁺ removal.
Why it’s right: Membrane stabilization buys minutes while shifting/removal therapies take effect.

6) Acid–Base — ABG basics

ABG: pH 7.28, PaCO₂ 60, HCO₃⁻ 27 in COPD exacerbation. What’s the disorder?
Answer: Primary respiratory acidosis with partial renal compensation.
Why it’s right: Low pH + high PaCO₂, modestly elevated HCO₃⁻ = acute-on-chronic CO₂ retention.

7) Acid–Base — mixed disorder check

A vomiting COPD patient: pH 7.38, PaCO₂ 52, HCO₃⁻ 31. Interpretation?
Answer: Mixed respiratory acidosis + metabolic alkalosis.
Why it’s right: Nearly normal pH but both PaCO₂ and HCO₃⁻ are high → opposing primary processes.

8) Pain — multimodal bundle

POD1 bowel resection, pain 7/10 despite opioids. Best non-opioid combo?
Answer: Scheduled acetaminophen ± NSAID (if renal/bleeding ok), ice/splinting, positioning, guided breathing, early mobilization.
Why it’s right: Multimodal therapy reduces opioid need and improves function (cough/ambulation).

9) PCA safety

Family presses the PCA while patient sleeps. Your response?
Answer: Educate: no-proxy PCA; only the patient may press. Evaluate sedation and analgesia plan.
Why it’s right: Sedation serves as a safety brake; proxy dosing risks respiratory depression.

10) Mobility/MSK — traction

A femur fracture on skeletal traction has weights resting on the floor. What do you do?
Answer: Reposition so weights hang freely; reassess alignment and pin sites.
Why it’s right: Continuous, aligned force is essential; resting weights cancel traction and injure tissue.