NUR209/ NUR 209 ( 2025/2026 Update) Medical Surgical Nursing II| Review
with Questions and Verified Answers| 100% Correct| Grade A – Fortis
Question 1
A nurse is caring for a client who is experiencing Atrial Fibrillation (AFib). Which of the
following potential complications should the nurse identify as the priority to monitor for?
A) Cardiac output of 5 L/min
B) Pulmonary embolism
C) Cerebrovascular accident (Stroke)
D) Peripheral edema
E) Urinary tract infection
Correct Answer: C) Cerebrovascular accident (Stroke)
Rationale: In Atrial Fibrillation, the atria do not contract effectively, leading to stasis of
blood in the left atrium. This stagnant blood is prone to forming clots (thrombi). If a clot
dislodges, it can travel through the arterial circulation to the brain, causing an embolic
stroke. While heart failure and peripheral edema are long-term concerns, the immediate
life-altering risk is a thromboembolic event.
Question 2
A nurse is reviewing the EKG strip of a client and notes a "sawtooth" waveform between the
QRS complexes. Which of the following rhythm disturbances is the client experiencing?
A) Atrial fibrillation
B) Atrial flutter
C) Ventricular tachycardia
D) First-degree AV block
E) Sinus bradycardia
Correct Answer: B) Atrial flutter
Rationale: Atrial flutter is characterized by a "sawtooth" pattern of P-waves (referred to as
F-waves). This occurs because of a reentrant circuit in the atria that fires at a very rapid,
regular rate (usually 250-350 bpm). Atrial fibrillation is irregular and lacks distinct P-
waves, while Ventricular Tachycardia has wide, bizarre QRS complexes.
Question 3
A nurse is assessing a client who is in the compensatory stage of shock. Which of the following
clinical manifestations should the nurse expect?
A) Bradycardia and bradypnea
B) Hypothermia and oliguria
C) Tachycardia and narrowed pulse pressure
D) Increased bowel sounds and diarrhea
E) Hypertension and clear lung sounds
, 2
Correct Answer: C) Tachycardia and narrowed pulse pressure
Rationale: In the compensatory stage of shock, the body’s sympathetic nervous system is
activated to maintain cardiac output and blood pressure. Tachycardia occurs as the heart
tries to move blood faster. Vasoconstriction occurs to redirect blood to vital organs, leading
to a narrowed pulse pressure (the difference between systolic and diastolic BP). Oliguria
and cool skin may begin, but tachycardia is a hallmark early sign.
Question 4
A nurse is caring for a client with a permanent pacemaker. Which of the following EKG findings
indicates that the pacemaker is functioning correctly in "demand" mode?
A) Pacer spikes occur regularly regardless of the client's intrinsic heart rate.
B) Pacer spikes occur only when the client's heart rate drops below a set limit.
C) There are no pacer spikes, but the QRS complex is wide.
D) Pacer spikes are followed by a flat line.
E) Pacer spikes appear during the T-wave.
Correct Answer: B) Pacer spikes occur only when the client's heart rate drops below a set
limit.
Rationale: A demand pacemaker is programmed to monitor the heart's intrinsic rhythm
and only fires ("paces") when the patient's own rate falls below a predetermined threshold.
This prevents competition between the pacemaker and the heart's natural rhythm and
conserves battery life.
Question 5
A client is admitted with an Acute Myocardial Infarction (AMI). The nurse notes ST-segment
elevation in leads II, III, and aVF. Which area of the heart is primarily affected?
A) Anterior wall
B) Lateral wall
C) Septal wall
D) Inferior wall
E) Posterior wall
Correct Answer: D) Inferior wall
Rationale: Leads II, III, and aVF look at the inferior portion of the heart, which is usually
supplied by the Right Coronary Artery (RCA). ST-elevation in these leads suggests an
inferior wall MI. Understanding lead placement helps the nurse anticipate specific
complications, such as bradycardia or heart blocks, which are common in RCA occlusions.
Question 6
A nurse is preparing to administer Adenosine to a client with Supraventricular Tachycardia
(SVT). Which of the following nursing actions is essential during administration?
A) Administer the medication over 2 to 3 minutes.
, 3
B) Instruct the client to perform the Valsalva maneuver during injection.
C) Use the IV port furthest from the heart.
D) Administer the medication via rapid IV bolus followed by a saline flush.
E) Check the client’s blood glucose before administration.
Correct Answer: D) Administer the medication via rapid IV bolus followed by a saline flush.
Rationale: Adenosine has an extremely short half-life (less than 10 seconds). Therefore, it
must be given as a very rapid IV push (1-2 seconds) through a peripheral line as close to
the heart as possible (e.g., antecubital) followed immediately by a rapid saline flush to
ensure the drug reaches the cardiac tissue before it is metabolized.
Question 7
A nurse is caring for a client with Hypovolemic Shock. Which of the following IV fluids should
the nurse anticipate administering first to restore intravascular volume?
A) 0.45% Sodium Chloride (Half Normal Saline)
B) 5% Dextrose in Water (D5W)
C) 0.9% Sodium Chloride (Normal Saline)
D) 3% Sodium Chloride (Hypertonic Saline)
E) 10% Dextrose in Water
Correct Answer: C) 0.9% Sodium Chloride (Normal Saline)
Rationale: Isotonic crystalloids, such as 0.9% Sodium Chloride or Lactated Ringer’s, are
the first-line treatment for hypovolemic shock because they expand the extracellular fluid
volume without shifting water into or out of the cells. 0.45% NaCl is hypotonic and would
leave the intravascular space, while 3% NaCl is hypertonic and used only for severe
hyponatremia/cerebral edema.
Question 8
A nurse is monitoring a client following a Percutaneous Coronary Intervention (PCI) with stent
placement via the femoral artery. Which finding requires immediate intervention?
A) A 1+ pedal pulse on the affected extremity.
B) Report of discomfort at the insertion site.
C) A heart rate of 88 bpm.
D) A hematoma noted at the femoral puncture site.
E) Increased urinary output.
Correct Answer: D) A hematoma noted at the femoral puncture site.
Rationale: Post-PCI, the client is at high risk for bleeding and hematoma formation at the
arterial puncture site due to the large bore sheath used and the administration of
anticoagulants. A hematoma can indicate internal bleeding and lead to retroperitoneal
hemorrhage. The nurse must apply manual pressure and notify the provider immediately.
, 4
Question 9
A client with Chronic Obstructive Pulmonary Disease (COPD) is being evaluated for an acute
exacerbation. The ABG results are: pH 7.31, PaCO2 55, HCO3 28. How should the nurse
interpret these results?
A) Fully compensated respiratory acidosis
B) Partially compensated respiratory acidosis
C) Uncompensated metabolic acidosis
D) Partially compensated respiratory alkalosis
E) Normal ABG for a COPD client
Correct Answer: B) Partially compensated respiratory acidosis
Rationale: The pH is low (<7.35), indicating acidosis. The PaCO2 is high (>45), which is the
cause of the acidosis (respiratory). The HCO3 is high (>26), indicating that the kidneys are
attempting to buffer the acid by retaining bicarbonate. Because the pH has not yet
returned to the normal range, the compensation is described as "partially compensated."
Question 10
A nurse is assessing a client with Right-Sided Heart Failure. Which of the following clinical
findings should the nurse expect?
A) Crackles in the lung bases
B) Paroxysmal nocturnal dyspnea
C) Jugular Venous Distention (JVD)
D) Orthopnea
E) Frothy, pink-tinged sputum
Correct Answer: C) Jugular Venous Distention (JVD)
Rationale: Right-sided heart failure causes blood to back up into the systemic venous
circulation. This leads to JVD, peripheral edema, hepatomegaly, and ascites. Crackles,
orthopnea, and frothy sputum are clinical manifestations of Left-Sided Heart Failure,
where blood backs up into the pulmonary circulation.
Question 11
A client is diagnosed with Cardiac Tamponade. Which of the following findings should the nurse
identify as part of Beck's Triad?
A) Hypertension, bradycardia, widened pulse pressure
B) Hypotension, JVD, muffled heart sounds
C) Tachycardia, tachypnea, clear breath sounds
D) Fever, chills, pleuritic chest pain
E) S3 gallop, crackles, wheezing
Correct Answer: B) Hypotension, JVD, muffled heart sounds
Rationale: Beck's Triad is the classic set of signs for cardiac tamponade: Hypotension (due
with Questions and Verified Answers| 100% Correct| Grade A – Fortis
Question 1
A nurse is caring for a client who is experiencing Atrial Fibrillation (AFib). Which of the
following potential complications should the nurse identify as the priority to monitor for?
A) Cardiac output of 5 L/min
B) Pulmonary embolism
C) Cerebrovascular accident (Stroke)
D) Peripheral edema
E) Urinary tract infection
Correct Answer: C) Cerebrovascular accident (Stroke)
Rationale: In Atrial Fibrillation, the atria do not contract effectively, leading to stasis of
blood in the left atrium. This stagnant blood is prone to forming clots (thrombi). If a clot
dislodges, it can travel through the arterial circulation to the brain, causing an embolic
stroke. While heart failure and peripheral edema are long-term concerns, the immediate
life-altering risk is a thromboembolic event.
Question 2
A nurse is reviewing the EKG strip of a client and notes a "sawtooth" waveform between the
QRS complexes. Which of the following rhythm disturbances is the client experiencing?
A) Atrial fibrillation
B) Atrial flutter
C) Ventricular tachycardia
D) First-degree AV block
E) Sinus bradycardia
Correct Answer: B) Atrial flutter
Rationale: Atrial flutter is characterized by a "sawtooth" pattern of P-waves (referred to as
F-waves). This occurs because of a reentrant circuit in the atria that fires at a very rapid,
regular rate (usually 250-350 bpm). Atrial fibrillation is irregular and lacks distinct P-
waves, while Ventricular Tachycardia has wide, bizarre QRS complexes.
Question 3
A nurse is assessing a client who is in the compensatory stage of shock. Which of the following
clinical manifestations should the nurse expect?
A) Bradycardia and bradypnea
B) Hypothermia and oliguria
C) Tachycardia and narrowed pulse pressure
D) Increased bowel sounds and diarrhea
E) Hypertension and clear lung sounds
, 2
Correct Answer: C) Tachycardia and narrowed pulse pressure
Rationale: In the compensatory stage of shock, the body’s sympathetic nervous system is
activated to maintain cardiac output and blood pressure. Tachycardia occurs as the heart
tries to move blood faster. Vasoconstriction occurs to redirect blood to vital organs, leading
to a narrowed pulse pressure (the difference between systolic and diastolic BP). Oliguria
and cool skin may begin, but tachycardia is a hallmark early sign.
Question 4
A nurse is caring for a client with a permanent pacemaker. Which of the following EKG findings
indicates that the pacemaker is functioning correctly in "demand" mode?
A) Pacer spikes occur regularly regardless of the client's intrinsic heart rate.
B) Pacer spikes occur only when the client's heart rate drops below a set limit.
C) There are no pacer spikes, but the QRS complex is wide.
D) Pacer spikes are followed by a flat line.
E) Pacer spikes appear during the T-wave.
Correct Answer: B) Pacer spikes occur only when the client's heart rate drops below a set
limit.
Rationale: A demand pacemaker is programmed to monitor the heart's intrinsic rhythm
and only fires ("paces") when the patient's own rate falls below a predetermined threshold.
This prevents competition between the pacemaker and the heart's natural rhythm and
conserves battery life.
Question 5
A client is admitted with an Acute Myocardial Infarction (AMI). The nurse notes ST-segment
elevation in leads II, III, and aVF. Which area of the heart is primarily affected?
A) Anterior wall
B) Lateral wall
C) Septal wall
D) Inferior wall
E) Posterior wall
Correct Answer: D) Inferior wall
Rationale: Leads II, III, and aVF look at the inferior portion of the heart, which is usually
supplied by the Right Coronary Artery (RCA). ST-elevation in these leads suggests an
inferior wall MI. Understanding lead placement helps the nurse anticipate specific
complications, such as bradycardia or heart blocks, which are common in RCA occlusions.
Question 6
A nurse is preparing to administer Adenosine to a client with Supraventricular Tachycardia
(SVT). Which of the following nursing actions is essential during administration?
A) Administer the medication over 2 to 3 minutes.
, 3
B) Instruct the client to perform the Valsalva maneuver during injection.
C) Use the IV port furthest from the heart.
D) Administer the medication via rapid IV bolus followed by a saline flush.
E) Check the client’s blood glucose before administration.
Correct Answer: D) Administer the medication via rapid IV bolus followed by a saline flush.
Rationale: Adenosine has an extremely short half-life (less than 10 seconds). Therefore, it
must be given as a very rapid IV push (1-2 seconds) through a peripheral line as close to
the heart as possible (e.g., antecubital) followed immediately by a rapid saline flush to
ensure the drug reaches the cardiac tissue before it is metabolized.
Question 7
A nurse is caring for a client with Hypovolemic Shock. Which of the following IV fluids should
the nurse anticipate administering first to restore intravascular volume?
A) 0.45% Sodium Chloride (Half Normal Saline)
B) 5% Dextrose in Water (D5W)
C) 0.9% Sodium Chloride (Normal Saline)
D) 3% Sodium Chloride (Hypertonic Saline)
E) 10% Dextrose in Water
Correct Answer: C) 0.9% Sodium Chloride (Normal Saline)
Rationale: Isotonic crystalloids, such as 0.9% Sodium Chloride or Lactated Ringer’s, are
the first-line treatment for hypovolemic shock because they expand the extracellular fluid
volume without shifting water into or out of the cells. 0.45% NaCl is hypotonic and would
leave the intravascular space, while 3% NaCl is hypertonic and used only for severe
hyponatremia/cerebral edema.
Question 8
A nurse is monitoring a client following a Percutaneous Coronary Intervention (PCI) with stent
placement via the femoral artery. Which finding requires immediate intervention?
A) A 1+ pedal pulse on the affected extremity.
B) Report of discomfort at the insertion site.
C) A heart rate of 88 bpm.
D) A hematoma noted at the femoral puncture site.
E) Increased urinary output.
Correct Answer: D) A hematoma noted at the femoral puncture site.
Rationale: Post-PCI, the client is at high risk for bleeding and hematoma formation at the
arterial puncture site due to the large bore sheath used and the administration of
anticoagulants. A hematoma can indicate internal bleeding and lead to retroperitoneal
hemorrhage. The nurse must apply manual pressure and notify the provider immediately.
, 4
Question 9
A client with Chronic Obstructive Pulmonary Disease (COPD) is being evaluated for an acute
exacerbation. The ABG results are: pH 7.31, PaCO2 55, HCO3 28. How should the nurse
interpret these results?
A) Fully compensated respiratory acidosis
B) Partially compensated respiratory acidosis
C) Uncompensated metabolic acidosis
D) Partially compensated respiratory alkalosis
E) Normal ABG for a COPD client
Correct Answer: B) Partially compensated respiratory acidosis
Rationale: The pH is low (<7.35), indicating acidosis. The PaCO2 is high (>45), which is the
cause of the acidosis (respiratory). The HCO3 is high (>26), indicating that the kidneys are
attempting to buffer the acid by retaining bicarbonate. Because the pH has not yet
returned to the normal range, the compensation is described as "partially compensated."
Question 10
A nurse is assessing a client with Right-Sided Heart Failure. Which of the following clinical
findings should the nurse expect?
A) Crackles in the lung bases
B) Paroxysmal nocturnal dyspnea
C) Jugular Venous Distention (JVD)
D) Orthopnea
E) Frothy, pink-tinged sputum
Correct Answer: C) Jugular Venous Distention (JVD)
Rationale: Right-sided heart failure causes blood to back up into the systemic venous
circulation. This leads to JVD, peripheral edema, hepatomegaly, and ascites. Crackles,
orthopnea, and frothy sputum are clinical manifestations of Left-Sided Heart Failure,
where blood backs up into the pulmonary circulation.
Question 11
A client is diagnosed with Cardiac Tamponade. Which of the following findings should the nurse
identify as part of Beck's Triad?
A) Hypertension, bradycardia, widened pulse pressure
B) Hypotension, JVD, muffled heart sounds
C) Tachycardia, tachypnea, clear breath sounds
D) Fever, chills, pleuritic chest pain
E) S3 gallop, crackles, wheezing
Correct Answer: B) Hypotension, JVD, muffled heart sounds
Rationale: Beck's Triad is the classic set of signs for cardiac tamponade: Hypotension (due
