NURSING Med Surg 2 SAUNDERS
COMPREHENSIVE REVIEW FOR
NCLEX FOUR Completed and
Graded A+ Latest Edition 2026
Course
NURSING Med Surg 2 (NURSINGMEDSURG2)
1. A client with heart failure reports increasing shortness of breath and a weight gain of 2.7 kg
(6 lb) in one week. What is the nurse's priority action?
A. Encourage increased fluid intake.
B. Notify the healthcare provider.
C. Administer a stool softener.
D. Encourage ambulation.
✅ Correct Answer: B. Notify the healthcare provider.
Rationale
Rapid weight gain and worsening dyspnea indicate fluid overload and worsening heart failure
that requires prompt evaluation and possible adjustment of diuretic therapy.
2. Which assessment finding is most indicative of left-sided heart failure?
A. Jugular vein distention
B. Peripheral edema
C. Crackles in both lung bases
D. Hepatomegaly
✅ Correct Answer: C. Crackles in both lung bases
Rationale
Left-sided heart failure causes pulmonary congestion, leading to crackles, dyspnea, orthopnea,
and pulmonary edema.
,3. A client develops sudden crushing chest pain radiating to the left arm. Which action should
the nurse perform first?
A. Obtain a 12-lead ECG.
B. Administer morphine.
C. Assess airway, breathing, and circulation.
D. Encourage the client to rest.
✅ Correct Answer: C. Assess airway, breathing, and circulation.
Rationale
Initial assessment of airway, breathing, and circulation (ABCs) is the priority before
implementing additional interventions.
4. Which laboratory value is the most specific indicator of myocardial injury?
A. Creatine kinase
B. Troponin I
C. Myoglobin
D. BNP
✅ Correct Answer: B. Troponin I
Rationale
Cardiac troponins are highly sensitive and specific biomarkers for myocardial infarction.
5. A client with atrial fibrillation has a heart rate of 150 beats/min. Which complication is the
highest priority?
A. Constipation
B. Thromboembolism
C. Urinary retention
D. Hypocalcemia
✅ Correct Answer: B. Thromboembolism
,Rationale
Blood pooling in the atria increases the risk of clot formation and embolic stroke.
6. Which intervention is most appropriate for a client with deep vein thrombosis (DVT)?
A. Massage the affected leg.
B. Encourage vigorous ambulation.
C. Elevate the affected extremity.
D. Apply sequential compression devices to the affected leg.
✅ Correct Answer: C. Elevate the affected extremity.
Rationale
Elevation reduces edema and promotes venous return. Massaging the leg may dislodge the clot.
7. Which assessment finding is expected in pulmonary embolism?
A. Bradycardia
B. Sudden dyspnea and pleuritic chest pain
C. Hypertension
D. Bilateral pedal edema only
✅ Correct Answer: B. Sudden dyspnea and pleuritic chest pain
Rationale
Pulmonary embolism commonly presents with sudden shortness of breath, pleuritic chest pain,
tachycardia, and hypoxemia.
8. Which oxygen delivery device provides the highest oxygen concentration without
intubation?
A. Nasal cannula
B. Simple face mask
C. Venturi mask
, D. Non-rebreather mask
✅ Correct Answer: D. Non-rebreather mask
Rationale
A non-rebreather mask can deliver approximately 60%–95% oxygen when properly fitted.
9. Which assessment finding is most consistent with chronic obstructive pulmonary disease
(COPD)?
A. Bradycardia
B. Barrel-shaped chest
C. Productive cough with pink frothy sputum
D. Clubbing only
✅ Correct Answer: B. Barrel-shaped chest
Rationale
Hyperinflation of the lungs produces the characteristic barrel chest seen in emphysema.
10. A client with COPD is receiving oxygen therapy. Which oxygen saturation goal is
appropriate for many stable COPD patients?
A. 100%
B. 98%–100%
C. 88%–92%
D. Above 99%
✅ Correct Answer: C. 88%–92%
Rationale
Many clients with COPD are managed with a target SpO₂ of 88%–92% to provide adequate
oxygenation while reducing the risk of oxygen-induced hypercapnia. Targets should follow the
provider's orders and the client's clinical condition.
COMPREHENSIVE REVIEW FOR
NCLEX FOUR Completed and
Graded A+ Latest Edition 2026
Course
NURSING Med Surg 2 (NURSINGMEDSURG2)
1. A client with heart failure reports increasing shortness of breath and a weight gain of 2.7 kg
(6 lb) in one week. What is the nurse's priority action?
A. Encourage increased fluid intake.
B. Notify the healthcare provider.
C. Administer a stool softener.
D. Encourage ambulation.
✅ Correct Answer: B. Notify the healthcare provider.
Rationale
Rapid weight gain and worsening dyspnea indicate fluid overload and worsening heart failure
that requires prompt evaluation and possible adjustment of diuretic therapy.
2. Which assessment finding is most indicative of left-sided heart failure?
A. Jugular vein distention
B. Peripheral edema
C. Crackles in both lung bases
D. Hepatomegaly
✅ Correct Answer: C. Crackles in both lung bases
Rationale
Left-sided heart failure causes pulmonary congestion, leading to crackles, dyspnea, orthopnea,
and pulmonary edema.
,3. A client develops sudden crushing chest pain radiating to the left arm. Which action should
the nurse perform first?
A. Obtain a 12-lead ECG.
B. Administer morphine.
C. Assess airway, breathing, and circulation.
D. Encourage the client to rest.
✅ Correct Answer: C. Assess airway, breathing, and circulation.
Rationale
Initial assessment of airway, breathing, and circulation (ABCs) is the priority before
implementing additional interventions.
4. Which laboratory value is the most specific indicator of myocardial injury?
A. Creatine kinase
B. Troponin I
C. Myoglobin
D. BNP
✅ Correct Answer: B. Troponin I
Rationale
Cardiac troponins are highly sensitive and specific biomarkers for myocardial infarction.
5. A client with atrial fibrillation has a heart rate of 150 beats/min. Which complication is the
highest priority?
A. Constipation
B. Thromboembolism
C. Urinary retention
D. Hypocalcemia
✅ Correct Answer: B. Thromboembolism
,Rationale
Blood pooling in the atria increases the risk of clot formation and embolic stroke.
6. Which intervention is most appropriate for a client with deep vein thrombosis (DVT)?
A. Massage the affected leg.
B. Encourage vigorous ambulation.
C. Elevate the affected extremity.
D. Apply sequential compression devices to the affected leg.
✅ Correct Answer: C. Elevate the affected extremity.
Rationale
Elevation reduces edema and promotes venous return. Massaging the leg may dislodge the clot.
7. Which assessment finding is expected in pulmonary embolism?
A. Bradycardia
B. Sudden dyspnea and pleuritic chest pain
C. Hypertension
D. Bilateral pedal edema only
✅ Correct Answer: B. Sudden dyspnea and pleuritic chest pain
Rationale
Pulmonary embolism commonly presents with sudden shortness of breath, pleuritic chest pain,
tachycardia, and hypoxemia.
8. Which oxygen delivery device provides the highest oxygen concentration without
intubation?
A. Nasal cannula
B. Simple face mask
C. Venturi mask
, D. Non-rebreather mask
✅ Correct Answer: D. Non-rebreather mask
Rationale
A non-rebreather mask can deliver approximately 60%–95% oxygen when properly fitted.
9. Which assessment finding is most consistent with chronic obstructive pulmonary disease
(COPD)?
A. Bradycardia
B. Barrel-shaped chest
C. Productive cough with pink frothy sputum
D. Clubbing only
✅ Correct Answer: B. Barrel-shaped chest
Rationale
Hyperinflation of the lungs produces the characteristic barrel chest seen in emphysema.
10. A client with COPD is receiving oxygen therapy. Which oxygen saturation goal is
appropriate for many stable COPD patients?
A. 100%
B. 98%–100%
C. 88%–92%
D. Above 99%
✅ Correct Answer: C. 88%–92%
Rationale
Many clients with COPD are managed with a target SpO₂ of 88%–92% to provide adequate
oxygenation while reducing the risk of oxygen-induced hypercapnia. Targets should follow the
provider's orders and the client's clinical condition.
