NUR 209 / NUR209 Medical Surgical Nursing II Exam 1
Actual 2024/2025 with Detailed Rationales | 100%
Verified | Pass Guaranteed – A+ Graded
SECTION 1: Foundations of Medical-Surgical Nursing
(Questions 1–10)
Q1: A nurse is caring for a postoperative patient who had abdominal surgery 8 hours
ago. The patient reports pain rated 7/10 and has not yet passed flatus. Which
nursing intervention is the priority?
A. Administering a large volume oral laxative
B. Administering prescribed analgesics and encouraging early ambulation
[CORRECT]
C. Keeping the patient NPO and inserting a nasogastric tube
D. Encouraging the patient to bear down and strain during bowel movements
Correct Answer: B
Rationale: Correct because postoperative pain management and early ambulation
are essential for promoting peristalsis, preventing ileus, and facilitating return of
bowel function after abdominal surgery.
Q2: Which nursing action is most effective in preventing healthcare-associated
infections (HAIs)?
A. Administering prophylactic antibiotics to all patients
B. Consistent hand hygiene before and after every patient contact [CORRECT]
C. Wearing gloves for all patient interactions regardless of exposure risk
D. Isolating all postoperative patients in private rooms
Correct Answer: B
Rationale: Correct because hand hygiene is the single most effective measure for
preventing the transmission of pathogens and reducing healthcare-associated
infections.
,Q3: A patient with diabetes mellitus has a fasting blood glucose of 248 mg/dL.
Which nursing intervention is the priority?
A. Encouraging the patient to eat a high-carbohydrate snack
B. Administering prescribed insulin and monitoring for signs of hyperglycemia
[CORRECT]
C. Withholding all medications until glucose normalizes
D. Increasing oral fluid intake with sugary beverages
Correct Answer: B
Rationale: Correct because elevated fasting glucose requires insulin administration
per protocol; monitoring for hyperglycemia symptoms and preventing complications
are essential nursing priorities.
Q4: Which assessment finding in a postoperative patient requires immediate
notification of the surgeon?
A. Mild incisional pain rated 4/10
B. Serous drainage on the surgical dressing
C. Wound dehiscence with protrusion of abdominal contents [CORRECT]
D. Temperature of 99.2°F on postoperative day 1
Correct Answer: C
Rationale: Correct because wound dehiscence with evisceration is a surgical
emergency requiring immediate intervention to prevent infection, tissue damage, and
sepsis.
Q5: A nurse is caring for a patient receiving patient-controlled analgesia (PCA).
Which assessment finding indicates a potential complication?
A. Pain rating decreased from 8/10 to 3/10 after dosing
B. Respiratory rate of 8 breaths/min with decreased level of consciousness
[CORRECT]
C. Patient pressing the PCA button every 2 hours
D. Mild nausea relieved by antiemetics
Correct Answer: B
Rationale: Correct because respiratory depression (rate <10 breaths/min) with
altered mental status indicates opioid-induced respiratory compromise, requiring
immediate naloxone administration and provider notification.
Q6: Which nursing intervention is most appropriate for preventing deep vein
thrombosis (DVT) in a postoperative patient?
A. Keeping the patient on strict bed rest for 72 hours
, B. Early ambulation, sequential compression devices, and anticoagulant prophylaxis
as ordered [CORRECT]
C. Applying warm compresses to the lower extremities
D. Encouraging the patient to cross their legs while sitting
Correct Answer: B
Rationale: Correct because early ambulation promotes venous return, SCDs enhance
circulation, and pharmacologic prophylaxis reduces hypercoagulability, collectively
preventing DVT formation.
Q7: A patient with a nasogastric tube reports nausea and has 400 mL of bright red
drainage in the collection container. Which action is the priority?
A. Irrigate the nasogastric tube with 30 mL of normal saline
B. Assess vital signs, maintain NPO status, and notify the provider immediately
[CORRECT]
C. Remove the nasogastric tube and replace it with a larger bore tube
D. Administer oral antacids through the tube
Correct Answer: B
Rationale: Correct because bright red nasogastric drainage indicates active upper GI
bleeding; the priority is hemodynamic assessment, maintaining NPO status, and
immediate provider notification.
Q8: Which laboratory value indicates adequate tissue perfusion in a patient with
septic shock?
A. Lactate level of 4.5 mmol/L
B. Urine output of 0.3 mL/kg/hr
C. Central venous oxygen saturation (ScvO₂) of 75% [CORRECT]
D. Serum creatinine of 2.8 mg/dL
Correct Answer: C
Rationale: Correct because ScvO₂ ≥70% indicates adequate oxygen delivery relative
to tissue oxygen consumption, reflecting appropriate tissue perfusion in sepsis
resuscitation.
Q9: A patient with heart failure is prescribed furosemide 40 mg IV daily. Which
assessment finding indicates the medication is effective?
A. Weight gain of 3 lb in 24 hours
B. Decreased peripheral edema and increased urine output [CORRECT]
C. Increased blood pressure from 130/84 to 158/96 mmHg
D. Decreased urine output and dry mucous membranes
Correct Answer: B
Actual 2024/2025 with Detailed Rationales | 100%
Verified | Pass Guaranteed – A+ Graded
SECTION 1: Foundations of Medical-Surgical Nursing
(Questions 1–10)
Q1: A nurse is caring for a postoperative patient who had abdominal surgery 8 hours
ago. The patient reports pain rated 7/10 and has not yet passed flatus. Which
nursing intervention is the priority?
A. Administering a large volume oral laxative
B. Administering prescribed analgesics and encouraging early ambulation
[CORRECT]
C. Keeping the patient NPO and inserting a nasogastric tube
D. Encouraging the patient to bear down and strain during bowel movements
Correct Answer: B
Rationale: Correct because postoperative pain management and early ambulation
are essential for promoting peristalsis, preventing ileus, and facilitating return of
bowel function after abdominal surgery.
Q2: Which nursing action is most effective in preventing healthcare-associated
infections (HAIs)?
A. Administering prophylactic antibiotics to all patients
B. Consistent hand hygiene before and after every patient contact [CORRECT]
C. Wearing gloves for all patient interactions regardless of exposure risk
D. Isolating all postoperative patients in private rooms
Correct Answer: B
Rationale: Correct because hand hygiene is the single most effective measure for
preventing the transmission of pathogens and reducing healthcare-associated
infections.
,Q3: A patient with diabetes mellitus has a fasting blood glucose of 248 mg/dL.
Which nursing intervention is the priority?
A. Encouraging the patient to eat a high-carbohydrate snack
B. Administering prescribed insulin and monitoring for signs of hyperglycemia
[CORRECT]
C. Withholding all medications until glucose normalizes
D. Increasing oral fluid intake with sugary beverages
Correct Answer: B
Rationale: Correct because elevated fasting glucose requires insulin administration
per protocol; monitoring for hyperglycemia symptoms and preventing complications
are essential nursing priorities.
Q4: Which assessment finding in a postoperative patient requires immediate
notification of the surgeon?
A. Mild incisional pain rated 4/10
B. Serous drainage on the surgical dressing
C. Wound dehiscence with protrusion of abdominal contents [CORRECT]
D. Temperature of 99.2°F on postoperative day 1
Correct Answer: C
Rationale: Correct because wound dehiscence with evisceration is a surgical
emergency requiring immediate intervention to prevent infection, tissue damage, and
sepsis.
Q5: A nurse is caring for a patient receiving patient-controlled analgesia (PCA).
Which assessment finding indicates a potential complication?
A. Pain rating decreased from 8/10 to 3/10 after dosing
B. Respiratory rate of 8 breaths/min with decreased level of consciousness
[CORRECT]
C. Patient pressing the PCA button every 2 hours
D. Mild nausea relieved by antiemetics
Correct Answer: B
Rationale: Correct because respiratory depression (rate <10 breaths/min) with
altered mental status indicates opioid-induced respiratory compromise, requiring
immediate naloxone administration and provider notification.
Q6: Which nursing intervention is most appropriate for preventing deep vein
thrombosis (DVT) in a postoperative patient?
A. Keeping the patient on strict bed rest for 72 hours
, B. Early ambulation, sequential compression devices, and anticoagulant prophylaxis
as ordered [CORRECT]
C. Applying warm compresses to the lower extremities
D. Encouraging the patient to cross their legs while sitting
Correct Answer: B
Rationale: Correct because early ambulation promotes venous return, SCDs enhance
circulation, and pharmacologic prophylaxis reduces hypercoagulability, collectively
preventing DVT formation.
Q7: A patient with a nasogastric tube reports nausea and has 400 mL of bright red
drainage in the collection container. Which action is the priority?
A. Irrigate the nasogastric tube with 30 mL of normal saline
B. Assess vital signs, maintain NPO status, and notify the provider immediately
[CORRECT]
C. Remove the nasogastric tube and replace it with a larger bore tube
D. Administer oral antacids through the tube
Correct Answer: B
Rationale: Correct because bright red nasogastric drainage indicates active upper GI
bleeding; the priority is hemodynamic assessment, maintaining NPO status, and
immediate provider notification.
Q8: Which laboratory value indicates adequate tissue perfusion in a patient with
septic shock?
A. Lactate level of 4.5 mmol/L
B. Urine output of 0.3 mL/kg/hr
C. Central venous oxygen saturation (ScvO₂) of 75% [CORRECT]
D. Serum creatinine of 2.8 mg/dL
Correct Answer: C
Rationale: Correct because ScvO₂ ≥70% indicates adequate oxygen delivery relative
to tissue oxygen consumption, reflecting appropriate tissue perfusion in sepsis
resuscitation.
Q9: A patient with heart failure is prescribed furosemide 40 mg IV daily. Which
assessment finding indicates the medication is effective?
A. Weight gain of 3 lb in 24 hours
B. Decreased peripheral edema and increased urine output [CORRECT]
C. Increased blood pressure from 130/84 to 158/96 mmHg
D. Decreased urine output and dry mucous membranes
Correct Answer: B
