NUR 209 MEDICAL-SURGICAL NURSING II EXAM | QUESTIONS AND
ANSWERS | VERIFIED ANSWERS PLUS RATIONALES | EXAM
ALREADY GRADED A+ | LATEST EXAM
1. A patient with chronic obstructive pulmonary disease (COPD) is experiencing increased
shortness of breath. Which intervention should the nurse implement first?
A. Encourage deep breathing exercises
B. Administer prescribed bronchodilator
C. Place the patient in a high Fowler’s position
D. Teach pursed-lip breathing
Answer: C. Place the patient in a high Fowler’s position
Rationale: High Fowler’s position promotes lung expansion and facilitates breathing,
which is a priority in acute dyspnea.
2. A patient is admitted with heart failure and is receiving furosemide. Which laboratory
value should the nurse monitor most closely?
A. Serum glucose
B. Serum potassium
C. Serum sodium
D. Blood urea nitrogen (BUN)
Answer: B. Serum potassium
Rationale: Furosemide is a loop diuretic that can cause hypokalemia; monitoring
potassium is critical to prevent cardiac arrhythmias.
3. The nurse is caring for a patient with acute pancreatitis. Which symptom is most
indicative of this condition?
A. Jaundice
B. Severe epigastric pain radiating to the back
C. Right lower quadrant pain
D. Frequent diarrhea
Answer: B. Severe epigastric pain radiating to the back
Rationale: Acute pancreatitis typically presents with severe epigastric pain that may
radiate to the back.
4. Which action should the nurse take when caring for a patient with a nasogastric tube to
prevent aspiration?
A. Keep the head of the bed flat
B. Irrigate the tube with 100 mL of water every hour
C. Maintain the head of the bed elevated at least 30 degrees
D. Clamp the tube between feedings
Answer: C. Maintain the head of the bed elevated at least 30 degrees
Rationale: Elevating the head reduces the risk of aspiration during enteral feeding.
5. A patient is receiving morphine for postoperative pain. Which finding indicates a
potentially serious adverse effect?
A. Mild nausea
B. Constipation
C. Respiratory rate of 8 breaths per minute
, D. Drowsiness
Answer: C. Respiratory rate of 8 breaths per minute
Rationale: Morphine can cause respiratory depression, which is a life-threatening
complication.
6. A patient with chronic kidney disease is on a potassium-restricted diet. Which food
should the nurse instruct the patient to avoid?
A. Apples
B. Oranges
C. Rice
D. Green beans
Answer: B. Oranges
Rationale: Oranges are high in potassium, which should be limited in chronic kidney
disease to prevent hyperkalemia.
7. Which assessment finding is most concerning for a patient with a pulmonary embolism?
A. Mild cough
B. Pleuritic chest pain
C. Dyspnea and sudden tachycardia
D. Low-grade fever
Answer: C. Dyspnea and sudden tachycardia
Rationale: Sudden onset of dyspnea and tachycardia are hallmark signs of pulmonary
embolism and require immediate intervention.
8. A patient is scheduled for a colonoscopy. Which instruction should the nurse give to the
patient?
A. Eat a high-fiber diet the day before
B. Drink clear liquids and take bowel prep as prescribed
C. Avoid fasting
D. Take iron supplements to prevent anemia
Answer: B. Drink clear liquids and take bowel prep as prescribed
Rationale: Clear liquids and bowel preparation are necessary to cleanse the colon for
optimal visualization during colonoscopy.
9. Which nursing action is most important for a patient with neutropenia?
A. Encourage oral hygiene twice daily
B. Restrict visitors
C. Monitor temperature every 8 hours
D. Use aseptic technique for all invasive procedures
Answer: D. Use aseptic technique for all invasive procedures
Rationale: Neutropenic patients are highly susceptible to infection, and strict aseptic
technique is essential to prevent infection.
10. A patient is experiencing hypovolemic shock. Which intervention should the nurse
implement first?
A. Administer prescribed antibiotics
B. Elevate the legs and keep the patient warm
C. Draw blood for cultures
D. Prepare for intubation
Answer: B. Elevate the legs and keep the patient warm
, Rationale: Elevating the legs improves venous return, and warming prevents
hypothermia, both of which are critical initial interventions in hypovolemic shock.
11. A patient with cirrhosis presents with ascites. Which intervention should the nurse
prioritize?
A. Encourage ambulation
B. Measure abdominal girth daily
C. Administer lactulose
D. Provide high-protein diet
Answer: B. Measure abdominal girth daily
Rationale: Monitoring abdominal girth helps track fluid accumulation and guides
management of ascites.
12. A patient is receiving heparin therapy. Which laboratory value should the nurse monitor
to ensure safe dosing?
A. Prothrombin time (PT)
B. Activated partial thromboplastin time (aPTT)
C. International normalized ratio (INR)
D. Platelet count
Answer: B. Activated partial thromboplastin time (aPTT)
Rationale: aPTT monitors the anticoagulant effect of heparin and ensures therapeutic
levels without risk of bleeding.
13. A patient with left-sided heart failure has pulmonary congestion. Which assessment
finding is expected?
A. Peripheral edema
B. Crackles in the lungs
C. Jugular vein distention
D. Hepatomegaly
Answer: B. Crackles in the lungs
Rationale: Left-sided heart failure causes pulmonary congestion, resulting in crackles
heard on auscultation.
14. A patient with deep vein thrombosis (DVT) is prescribed warfarin. Which instruction is
essential?
A. Avoid all physical activity
B. Use an electric razor for shaving
C. Increase intake of green leafy vegetables
D. Stop taking the drug if bruising occurs
Answer: B. Use an electric razor for shaving
Rationale: Warfarin increases bleeding risk; using an electric razor helps prevent cuts
and bleeding.
15. Which intervention is most important for a patient experiencing an acute asthma attack?
A. Encourage fluid intake
B. Administer prescribed short-acting bronchodilator
C. Teach breathing exercises
D. Apply oxygen via nasal cannula at 1 L/min
Answer: B. Administer prescribed short-acting bronchodilator
Rationale: Short-acting bronchodilators provide rapid relief of bronchospasm, which is
the priority in acute asthma.
, 16. A patient with a newly placed colostomy asks about care. Which statement indicates
correct understanding?
A. “I should change the appliance every week.”
B. “I need to empty the pouch when it is one-third full.”
C. “I can rinse the stoma with alcohol daily.”
D. “I should use adhesive remover every day.”
Answer: B. “I need to empty the pouch when it is one-third full.”
Rationale: Emptying the colostomy pouch when one-third full prevents leakage and skin
irritation.
17. A patient with diabetes mellitus is experiencing hypoglycemia. Which symptom should
the nurse assess for first?
A. Increased urination
B. Sweating and shakiness
C. Polydipsia
D. Blurred vision
Answer: B. Sweating and shakiness
Rationale: Hypoglycemia commonly presents with adrenergic symptoms like sweating
and shakiness, which require immediate intervention.
18. Which electrolyte imbalance is most concerning in a patient with prolonged diarrhea?
A. Hyperkalemia
B. Hypokalemia
C. Hypernatremia
D. Hyponatremia
Answer: B. Hypokalemia
Rationale: Diarrhea causes potassium loss, leading to hypokalemia, which can cause
cardiac dysrhythmias.
19. A patient with a gastric ulcer is prescribed omeprazole. Which teaching point is essential?
A. Take the medication with meals
B. Avoid antacids
C. Take the medication 30–60 minutes before meals
D. Stop the medication when pain resolves
Answer: C. Take the medication 30–60 minutes before meals
Rationale: Omeprazole, a proton pump inhibitor, is most effective when taken before
meals to reduce gastric acid secretion.
20. A patient with COPD has a pulse oximetry reading of 88%. Which action should the
nurse take first?
A. Administer prescribed bronchodilator
B. Encourage pursed-lip breathing
C. Apply supplemental oxygen per protocol
D. Call the physician
Answer: C. Apply supplemental oxygen per protocol
Rationale: Oxygenation is the priority; supplemental oxygen should be administered to
improve oxygen saturation.
21. A patient is receiving total parenteral nutrition (TPN). Which assessment finding
indicates a complication?
A. Mild nausea
ANSWERS | VERIFIED ANSWERS PLUS RATIONALES | EXAM
ALREADY GRADED A+ | LATEST EXAM
1. A patient with chronic obstructive pulmonary disease (COPD) is experiencing increased
shortness of breath. Which intervention should the nurse implement first?
A. Encourage deep breathing exercises
B. Administer prescribed bronchodilator
C. Place the patient in a high Fowler’s position
D. Teach pursed-lip breathing
Answer: C. Place the patient in a high Fowler’s position
Rationale: High Fowler’s position promotes lung expansion and facilitates breathing,
which is a priority in acute dyspnea.
2. A patient is admitted with heart failure and is receiving furosemide. Which laboratory
value should the nurse monitor most closely?
A. Serum glucose
B. Serum potassium
C. Serum sodium
D. Blood urea nitrogen (BUN)
Answer: B. Serum potassium
Rationale: Furosemide is a loop diuretic that can cause hypokalemia; monitoring
potassium is critical to prevent cardiac arrhythmias.
3. The nurse is caring for a patient with acute pancreatitis. Which symptom is most
indicative of this condition?
A. Jaundice
B. Severe epigastric pain radiating to the back
C. Right lower quadrant pain
D. Frequent diarrhea
Answer: B. Severe epigastric pain radiating to the back
Rationale: Acute pancreatitis typically presents with severe epigastric pain that may
radiate to the back.
4. Which action should the nurse take when caring for a patient with a nasogastric tube to
prevent aspiration?
A. Keep the head of the bed flat
B. Irrigate the tube with 100 mL of water every hour
C. Maintain the head of the bed elevated at least 30 degrees
D. Clamp the tube between feedings
Answer: C. Maintain the head of the bed elevated at least 30 degrees
Rationale: Elevating the head reduces the risk of aspiration during enteral feeding.
5. A patient is receiving morphine for postoperative pain. Which finding indicates a
potentially serious adverse effect?
A. Mild nausea
B. Constipation
C. Respiratory rate of 8 breaths per minute
, D. Drowsiness
Answer: C. Respiratory rate of 8 breaths per minute
Rationale: Morphine can cause respiratory depression, which is a life-threatening
complication.
6. A patient with chronic kidney disease is on a potassium-restricted diet. Which food
should the nurse instruct the patient to avoid?
A. Apples
B. Oranges
C. Rice
D. Green beans
Answer: B. Oranges
Rationale: Oranges are high in potassium, which should be limited in chronic kidney
disease to prevent hyperkalemia.
7. Which assessment finding is most concerning for a patient with a pulmonary embolism?
A. Mild cough
B. Pleuritic chest pain
C. Dyspnea and sudden tachycardia
D. Low-grade fever
Answer: C. Dyspnea and sudden tachycardia
Rationale: Sudden onset of dyspnea and tachycardia are hallmark signs of pulmonary
embolism and require immediate intervention.
8. A patient is scheduled for a colonoscopy. Which instruction should the nurse give to the
patient?
A. Eat a high-fiber diet the day before
B. Drink clear liquids and take bowel prep as prescribed
C. Avoid fasting
D. Take iron supplements to prevent anemia
Answer: B. Drink clear liquids and take bowel prep as prescribed
Rationale: Clear liquids and bowel preparation are necessary to cleanse the colon for
optimal visualization during colonoscopy.
9. Which nursing action is most important for a patient with neutropenia?
A. Encourage oral hygiene twice daily
B. Restrict visitors
C. Monitor temperature every 8 hours
D. Use aseptic technique for all invasive procedures
Answer: D. Use aseptic technique for all invasive procedures
Rationale: Neutropenic patients are highly susceptible to infection, and strict aseptic
technique is essential to prevent infection.
10. A patient is experiencing hypovolemic shock. Which intervention should the nurse
implement first?
A. Administer prescribed antibiotics
B. Elevate the legs and keep the patient warm
C. Draw blood for cultures
D. Prepare for intubation
Answer: B. Elevate the legs and keep the patient warm
, Rationale: Elevating the legs improves venous return, and warming prevents
hypothermia, both of which are critical initial interventions in hypovolemic shock.
11. A patient with cirrhosis presents with ascites. Which intervention should the nurse
prioritize?
A. Encourage ambulation
B. Measure abdominal girth daily
C. Administer lactulose
D. Provide high-protein diet
Answer: B. Measure abdominal girth daily
Rationale: Monitoring abdominal girth helps track fluid accumulation and guides
management of ascites.
12. A patient is receiving heparin therapy. Which laboratory value should the nurse monitor
to ensure safe dosing?
A. Prothrombin time (PT)
B. Activated partial thromboplastin time (aPTT)
C. International normalized ratio (INR)
D. Platelet count
Answer: B. Activated partial thromboplastin time (aPTT)
Rationale: aPTT monitors the anticoagulant effect of heparin and ensures therapeutic
levels without risk of bleeding.
13. A patient with left-sided heart failure has pulmonary congestion. Which assessment
finding is expected?
A. Peripheral edema
B. Crackles in the lungs
C. Jugular vein distention
D. Hepatomegaly
Answer: B. Crackles in the lungs
Rationale: Left-sided heart failure causes pulmonary congestion, resulting in crackles
heard on auscultation.
14. A patient with deep vein thrombosis (DVT) is prescribed warfarin. Which instruction is
essential?
A. Avoid all physical activity
B. Use an electric razor for shaving
C. Increase intake of green leafy vegetables
D. Stop taking the drug if bruising occurs
Answer: B. Use an electric razor for shaving
Rationale: Warfarin increases bleeding risk; using an electric razor helps prevent cuts
and bleeding.
15. Which intervention is most important for a patient experiencing an acute asthma attack?
A. Encourage fluid intake
B. Administer prescribed short-acting bronchodilator
C. Teach breathing exercises
D. Apply oxygen via nasal cannula at 1 L/min
Answer: B. Administer prescribed short-acting bronchodilator
Rationale: Short-acting bronchodilators provide rapid relief of bronchospasm, which is
the priority in acute asthma.
, 16. A patient with a newly placed colostomy asks about care. Which statement indicates
correct understanding?
A. “I should change the appliance every week.”
B. “I need to empty the pouch when it is one-third full.”
C. “I can rinse the stoma with alcohol daily.”
D. “I should use adhesive remover every day.”
Answer: B. “I need to empty the pouch when it is one-third full.”
Rationale: Emptying the colostomy pouch when one-third full prevents leakage and skin
irritation.
17. A patient with diabetes mellitus is experiencing hypoglycemia. Which symptom should
the nurse assess for first?
A. Increased urination
B. Sweating and shakiness
C. Polydipsia
D. Blurred vision
Answer: B. Sweating and shakiness
Rationale: Hypoglycemia commonly presents with adrenergic symptoms like sweating
and shakiness, which require immediate intervention.
18. Which electrolyte imbalance is most concerning in a patient with prolonged diarrhea?
A. Hyperkalemia
B. Hypokalemia
C. Hypernatremia
D. Hyponatremia
Answer: B. Hypokalemia
Rationale: Diarrhea causes potassium loss, leading to hypokalemia, which can cause
cardiac dysrhythmias.
19. A patient with a gastric ulcer is prescribed omeprazole. Which teaching point is essential?
A. Take the medication with meals
B. Avoid antacids
C. Take the medication 30–60 minutes before meals
D. Stop the medication when pain resolves
Answer: C. Take the medication 30–60 minutes before meals
Rationale: Omeprazole, a proton pump inhibitor, is most effective when taken before
meals to reduce gastric acid secretion.
20. A patient with COPD has a pulse oximetry reading of 88%. Which action should the
nurse take first?
A. Administer prescribed bronchodilator
B. Encourage pursed-lip breathing
C. Apply supplemental oxygen per protocol
D. Call the physician
Answer: C. Apply supplemental oxygen per protocol
Rationale: Oxygenation is the priority; supplemental oxygen should be administered to
improve oxygen saturation.
21. A patient is receiving total parenteral nutrition (TPN). Which assessment finding
indicates a complication?
A. Mild nausea
