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NUR 209 Final Med Surg II 2026/2027
Questions with Verified Answers and
Comprehensive Rationales Grade A
1. The nurse is documenting peripheral venous catheter insertion for a
client. What does the nurse include in the note? Select all that apply.
A) Client's name and hospital number
B) Client's response to the insertion
C) Date and time inserted
D) Type and size of device
E) Type of dressing applied
F) Vein used for insertion
Correct Answer: B) Client's response to the insertion, C) Date and time
inserted, D) Type and size of device, E) Type of dressing applied, and F)
Vein used for insertion
Rationale:
1. The client's ability to adapt to interventions, such as IV insertion, should be
noted when the intervention is performed.
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2. The date and time of the insertion are important data. IV sites need to be
routinely monitored and changed at prescribed intervals per facility policy.
3. It is important to note the device used (often the brand name is given), as well
as all specifics such as needle or cannula length, gauge, and material (Teflon).
4. It is necessary to describe the dressing applied, and the vein used should be
noted.
5. The client's name and hospital number should be on the medical record, but
the nurse makes certain that the information is recorded in the correct medical
record.
2. The nurse assessing a client's peripheral IV site obtains and
documents information about it. Which assessment data indicate the
need for immediate nursing intervention?
A) Client states, "It really hurt when the nurse put the IV in."
B) The vein feels hard and cordlike above the insertion site.
C) Transparent dressing was changed 5 days ago.
D) Tubing for the IV was last changed 72 hours ago.
Correct Answer: B) The vein feels hard and cordlike above the insertion
site.
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Rationale:
1. A hard, cordlike vein suggests phlebitis at the IV site and indicates an
immediate need for nursing intervention.
2. The IV should be discontinued and restarted at another site.
3. It is common for IVs to cause pain during insertion.
4. An intact transparent dressing requires changing only every 7 days.
5. Tubing for peripheral IVs should be changed every 72 to 96 hours.
3. The nurse is to administer a unit of whole blood to a postoperative
client. What does the nurse do to ensure the safety of the blood
transfusion?
A) Asks the client to both say and spell his or her full name before starting the
blood transfusion
B) Ensures that another qualified health care professional checks the unit
before administering
C) Checks the blood identification numbers with the laboratory technician at
the blood bank at the time it is dispensed
D) Makes certain that an IV solution of 0.9% normal saline is infusing into the
client before starting the unit
NUR 209 Final Med Surg II 2026/2027
Questions with Verified Answers and
Comprehensive Rationales Grade A
1. The nurse is documenting peripheral venous catheter insertion for a
client. What does the nurse include in the note? Select all that apply.
A) Client's name and hospital number
B) Client's response to the insertion
C) Date and time inserted
D) Type and size of device
E) Type of dressing applied
F) Vein used for insertion
Correct Answer: B) Client's response to the insertion, C) Date and time
inserted, D) Type and size of device, E) Type of dressing applied, and F)
Vein used for insertion
Rationale:
1. The client's ability to adapt to interventions, such as IV insertion, should be
noted when the intervention is performed.
,2|Page
2. The date and time of the insertion are important data. IV sites need to be
routinely monitored and changed at prescribed intervals per facility policy.
3. It is important to note the device used (often the brand name is given), as well
as all specifics such as needle or cannula length, gauge, and material (Teflon).
4. It is necessary to describe the dressing applied, and the vein used should be
noted.
5. The client's name and hospital number should be on the medical record, but
the nurse makes certain that the information is recorded in the correct medical
record.
2. The nurse assessing a client's peripheral IV site obtains and
documents information about it. Which assessment data indicate the
need for immediate nursing intervention?
A) Client states, "It really hurt when the nurse put the IV in."
B) The vein feels hard and cordlike above the insertion site.
C) Transparent dressing was changed 5 days ago.
D) Tubing for the IV was last changed 72 hours ago.
Correct Answer: B) The vein feels hard and cordlike above the insertion
site.
, 3|Page
Rationale:
1. A hard, cordlike vein suggests phlebitis at the IV site and indicates an
immediate need for nursing intervention.
2. The IV should be discontinued and restarted at another site.
3. It is common for IVs to cause pain during insertion.
4. An intact transparent dressing requires changing only every 7 days.
5. Tubing for peripheral IVs should be changed every 72 to 96 hours.
3. The nurse is to administer a unit of whole blood to a postoperative
client. What does the nurse do to ensure the safety of the blood
transfusion?
A) Asks the client to both say and spell his or her full name before starting the
blood transfusion
B) Ensures that another qualified health care professional checks the unit
before administering
C) Checks the blood identification numbers with the laboratory technician at
the blood bank at the time it is dispensed
D) Makes certain that an IV solution of 0.9% normal saline is infusing into the
client before starting the unit
