NUR 209 Medical-Surgical Nursing II 2026/2027 | NUR
209 Exam 1, 2, 3 & 4 Study Guide & Practice Test |
NUR209 Final Exam Review | Medical-Surgical Nursing
Questions, Answers & Detailed Rationales
Question 1: A nurse is preparing to administer an intramuscular injection to an
adult client. Which action should the nurse take first to ensure patient safety?
A. Select a 23-gauge needle for the injection
B. Verify the client's identity using two identifiers
C. Cleanse the injection site with an alcohol swab
D. Aspirate for blood return before injecting
CORRECT ANSWER: B. Verify the client's identity using two identifiers
Rationale: Verifying the client's identity using two approved identifiers (such as
name and medical record number or date of birth) is the critical first step before
any medication administration or invasive procedure. This prevents patient
identification errors and ensures the right medication is given to the right patient.
Selecting a needle, cleansing the site, and aspirating occur after identity
verification.
Question 2: A nurse is assessing a client who reports feeling short of breath.
Which finding should the nurse address first?
A. Respiratory rate of 30 breaths per minute
B. Mild anxiety about breathing
C. Dry lips and mucous membranes
D. Difficulty sleeping due to discomfort
CORRECT ANSWER: A. Respiratory rate of 30 breaths per minute
Rationale: A respiratory rate of 30 breaths per minute is significantly elevated and
indicates respiratory distress requiring immediate assessment and intervention.
The nurse should evaluate the client's airway, breathing pattern, oxygen
saturation, and work of breathing. Anxiety, dry lips, and sleep difficulty are
important but secondary to compromised respiratory status.
Question 3: A nurse is teaching a client about proper hand hygiene. Which
statement by the client indicates correct understanding?
,A. "I should wash my hands for at least 10 seconds."
B. "Alcohol-based sanitizer is effective when my hands are visibly soiled."
C. "I need to wash my hands for at least 20 seconds with soap and water."
D. "I only need to wash my hands after using the restroom."
CORRECT ANSWER: C. "I need to wash my hands for at least 20 seconds with
soap and water."
Rationale: The Centers for Disease Control and Prevention recommends washing
hands with soap and water for at least 20 seconds to effectively remove
pathogens. Alcohol-based sanitizer is not effective when hands are visibly soiled.
Hand hygiene should be performed at multiple points during patient care, not just
after restroom use.
Question 4: A nurse is caring for a postoperative client who is at risk for
developing deep vein thrombosis. Which intervention should the nurse include
in the care plan?
A. Encourage the client to remain on strict bed rest
B. Apply elastic compression stockings to the client's legs
C. Limit fluid intake to reduce edema formation
D. Keep the client's legs in a dependent position
CORRECT ANSWER: B. Apply elastic compression stockings to the client's legs
Rationale: Elastic compression stockings promote venous return and prevent
stasis of blood in the lower extremities, reducing the risk of deep vein thrombosis.
Early ambulation is also essential. Bed rest, fluid restriction, and dependent
positioning increase DVT risk rather than decrease it.
Question 5: A nurse is assessing a client with chronic renal failure who has a
potassium level of 6.5 mEq/L. Which action should the nurse anticipate taking?
A. Encourage oral potassium intake
B. Administer sodium polystyrene sulfonate
C. Restrict fluid intake only
D. Monitor potassium level in 24 hours
CORRECT ANSWER: B. Administer sodium polystyrene sulfonate
,Rationale: A potassium level of 6.5 mEq/L indicates severe hyperkalemia, which is
life-threatening due to risk of fatal cardiac dysrhythmias. Sodium polystyrene
sulfonate (Kayexalate) lowers potassium by binding it in the intestines and
promoting excretion. Immediate intervention is required; encouraging potassium
intake or delaying monitoring would worsen the condition.
Question 6: A client with newly diagnosed heart failure is being discharged.
Which statement indicates that teaching about daily weight monitoring has
been effective?
A. "I will weigh myself once a month."
B. "I should avoid all physical activity."
C. "I will call the clinic if my weight goes up 3 pounds in a week."
D. "Shortness of breath is expected and does not need reporting."
CORRECT ANSWER: C. "I will call the clinic if my weight goes up 3 pounds in a
week."
Rationale: Daily weight monitoring is critical for heart failure self-management
because sudden weight gain reflects fluid retention. A gain of 3 pounds in one
week may indicate worsening heart failure and requires prompt medical attention
to allow diuretic adjustment before symptoms become severe. Monthly weighing,
avoiding all activity, and ignoring dyspnea indicate misunderstanding.
Question 7: A nurse is developing a care plan for a patient with a new
colostomy. Which expected outcome is most appropriate?
A. The patient will verbalize understanding of the need for a permanent
colostomy
B. The patient will state feeling less anxious about the ostomy within 24 hours
C. The patient will demonstrate independent ostomy bag change with 90%
accuracy by discharge
D. The nurse will provide ostomy care education using a teach-back method daily
CORRECT ANSWER: C. The patient will demonstrate independent ostomy bag
change with 90% accuracy by discharge
Rationale: Expected outcomes must be patient-centered, measurable, and
realistic. Demonstrating the skill with specified accuracy is a measurable patient
, outcome that directly addresses the knowledge deficit. Verbalizing understanding
or stating less anxiety are less measurable. A nurse action is an intervention, not
an outcome.
Question 8: A nurse is caring for a client with COPD receiving supplemental
oxygen. The nurse notes the client's oxygen saturation is 92%. Which action
should the nurse take?
A. Increase the oxygen flow rate
B. Notify the healthcare provider immediately
C. Continue monitoring and maintain the current oxygen flow rate
D. Assess for signs of hypercapnia and consider decreasing oxygen
CORRECT ANSWER: D. Assess for signs of hypercapnia and consider decreasing
oxygen
Rationale: Clients with COPD are at risk for carbon dioxide retention because high
oxygen levels can suppress their respiratory drive. The target oxygen saturation
for COPD patients is typically 88-92%. While 92% is at the upper limit, the nurse
should assess for signs of hypercapnia (confusion, drowsiness, headache) and
consider decreasing oxygen if indicated.
Question 9: A nurse is prioritizing care for four patients at the beginning of a
shift. Which patient should the nurse see first?
A. A patient with a new ileostomy reporting incisional pain of 6/10
B. A patient with stable vital signs needing a scheduled wound dressing change
C. A patient with a potassium level of 5.8 mEq/L on a cardiac monitor
D. A patient needing assistance with a bed bath
CORRECT ANSWER: C. A patient with a potassium level of 5.8 mEq/L on a cardiac
monitor
Rationale: A potassium level of 5.8 mEq/L is a critical value that can cause life-
threatening cardiac dysrhythmias. Using Maslow's hierarchy of needs,
physiological needs that are life-threatening take highest priority. Pain, dressing
changes, and hygiene needs are important but do not pose immediate life
threats.
209 Exam 1, 2, 3 & 4 Study Guide & Practice Test |
NUR209 Final Exam Review | Medical-Surgical Nursing
Questions, Answers & Detailed Rationales
Question 1: A nurse is preparing to administer an intramuscular injection to an
adult client. Which action should the nurse take first to ensure patient safety?
A. Select a 23-gauge needle for the injection
B. Verify the client's identity using two identifiers
C. Cleanse the injection site with an alcohol swab
D. Aspirate for blood return before injecting
CORRECT ANSWER: B. Verify the client's identity using two identifiers
Rationale: Verifying the client's identity using two approved identifiers (such as
name and medical record number or date of birth) is the critical first step before
any medication administration or invasive procedure. This prevents patient
identification errors and ensures the right medication is given to the right patient.
Selecting a needle, cleansing the site, and aspirating occur after identity
verification.
Question 2: A nurse is assessing a client who reports feeling short of breath.
Which finding should the nurse address first?
A. Respiratory rate of 30 breaths per minute
B. Mild anxiety about breathing
C. Dry lips and mucous membranes
D. Difficulty sleeping due to discomfort
CORRECT ANSWER: A. Respiratory rate of 30 breaths per minute
Rationale: A respiratory rate of 30 breaths per minute is significantly elevated and
indicates respiratory distress requiring immediate assessment and intervention.
The nurse should evaluate the client's airway, breathing pattern, oxygen
saturation, and work of breathing. Anxiety, dry lips, and sleep difficulty are
important but secondary to compromised respiratory status.
Question 3: A nurse is teaching a client about proper hand hygiene. Which
statement by the client indicates correct understanding?
,A. "I should wash my hands for at least 10 seconds."
B. "Alcohol-based sanitizer is effective when my hands are visibly soiled."
C. "I need to wash my hands for at least 20 seconds with soap and water."
D. "I only need to wash my hands after using the restroom."
CORRECT ANSWER: C. "I need to wash my hands for at least 20 seconds with
soap and water."
Rationale: The Centers for Disease Control and Prevention recommends washing
hands with soap and water for at least 20 seconds to effectively remove
pathogens. Alcohol-based sanitizer is not effective when hands are visibly soiled.
Hand hygiene should be performed at multiple points during patient care, not just
after restroom use.
Question 4: A nurse is caring for a postoperative client who is at risk for
developing deep vein thrombosis. Which intervention should the nurse include
in the care plan?
A. Encourage the client to remain on strict bed rest
B. Apply elastic compression stockings to the client's legs
C. Limit fluid intake to reduce edema formation
D. Keep the client's legs in a dependent position
CORRECT ANSWER: B. Apply elastic compression stockings to the client's legs
Rationale: Elastic compression stockings promote venous return and prevent
stasis of blood in the lower extremities, reducing the risk of deep vein thrombosis.
Early ambulation is also essential. Bed rest, fluid restriction, and dependent
positioning increase DVT risk rather than decrease it.
Question 5: A nurse is assessing a client with chronic renal failure who has a
potassium level of 6.5 mEq/L. Which action should the nurse anticipate taking?
A. Encourage oral potassium intake
B. Administer sodium polystyrene sulfonate
C. Restrict fluid intake only
D. Monitor potassium level in 24 hours
CORRECT ANSWER: B. Administer sodium polystyrene sulfonate
,Rationale: A potassium level of 6.5 mEq/L indicates severe hyperkalemia, which is
life-threatening due to risk of fatal cardiac dysrhythmias. Sodium polystyrene
sulfonate (Kayexalate) lowers potassium by binding it in the intestines and
promoting excretion. Immediate intervention is required; encouraging potassium
intake or delaying monitoring would worsen the condition.
Question 6: A client with newly diagnosed heart failure is being discharged.
Which statement indicates that teaching about daily weight monitoring has
been effective?
A. "I will weigh myself once a month."
B. "I should avoid all physical activity."
C. "I will call the clinic if my weight goes up 3 pounds in a week."
D. "Shortness of breath is expected and does not need reporting."
CORRECT ANSWER: C. "I will call the clinic if my weight goes up 3 pounds in a
week."
Rationale: Daily weight monitoring is critical for heart failure self-management
because sudden weight gain reflects fluid retention. A gain of 3 pounds in one
week may indicate worsening heart failure and requires prompt medical attention
to allow diuretic adjustment before symptoms become severe. Monthly weighing,
avoiding all activity, and ignoring dyspnea indicate misunderstanding.
Question 7: A nurse is developing a care plan for a patient with a new
colostomy. Which expected outcome is most appropriate?
A. The patient will verbalize understanding of the need for a permanent
colostomy
B. The patient will state feeling less anxious about the ostomy within 24 hours
C. The patient will demonstrate independent ostomy bag change with 90%
accuracy by discharge
D. The nurse will provide ostomy care education using a teach-back method daily
CORRECT ANSWER: C. The patient will demonstrate independent ostomy bag
change with 90% accuracy by discharge
Rationale: Expected outcomes must be patient-centered, measurable, and
realistic. Demonstrating the skill with specified accuracy is a measurable patient
, outcome that directly addresses the knowledge deficit. Verbalizing understanding
or stating less anxiety are less measurable. A nurse action is an intervention, not
an outcome.
Question 8: A nurse is caring for a client with COPD receiving supplemental
oxygen. The nurse notes the client's oxygen saturation is 92%. Which action
should the nurse take?
A. Increase the oxygen flow rate
B. Notify the healthcare provider immediately
C. Continue monitoring and maintain the current oxygen flow rate
D. Assess for signs of hypercapnia and consider decreasing oxygen
CORRECT ANSWER: D. Assess for signs of hypercapnia and consider decreasing
oxygen
Rationale: Clients with COPD are at risk for carbon dioxide retention because high
oxygen levels can suppress their respiratory drive. The target oxygen saturation
for COPD patients is typically 88-92%. While 92% is at the upper limit, the nurse
should assess for signs of hypercapnia (confusion, drowsiness, headache) and
consider decreasing oxygen if indicated.
Question 9: A nurse is prioritizing care for four patients at the beginning of a
shift. Which patient should the nurse see first?
A. A patient with a new ileostomy reporting incisional pain of 6/10
B. A patient with stable vital signs needing a scheduled wound dressing change
C. A patient with a potassium level of 5.8 mEq/L on a cardiac monitor
D. A patient needing assistance with a bed bath
CORRECT ANSWER: C. A patient with a potassium level of 5.8 mEq/L on a cardiac
monitor
Rationale: A potassium level of 5.8 mEq/L is a critical value that can cause life-
threatening cardiac dysrhythmias. Using Maslow's hierarchy of needs,
physiological needs that are life-threatening take highest priority. Pain, dressing
changes, and hygiene needs are important but do not pose immediate life
threats.
