NUR209 / NUR 209 Medical Surgical Nursing II
Comprehensive Exam 2 - 100 Questions with ANSWERs
and Rationales
Updated for 2025/2026 Curriculum
EXAM QUESTIONS
Question 1:
A patient is placed on contact precautions. Which personal protective equipment (PPE) should the nurse
wear when entering the room?
A) Surgical mask only
B) N95 respirator and gloves
C) Gown and gloves
D) Gown, gloves, and mask
Correct ANSWER: C) Gown and gloves
Rationale: Contact precautions require the use of gown and gloves to prevent transmission of
microorganisms through direct contact with the patient or contaminated environmental surfaces. A
surgical mask is not required for standard contact precautions unless there is a risk of splash or spray.
N95 respirators are reserved for airborne precautions.
Question 2:
The nurse is assessing a patient's blood pressure using a cuff that is too large for the patient's arm. What
effect will this have on the reading?
,A) Falsely high reading
B) Falsely low reading
C) No effect on the reading
D) Unable to obtain a reading
Correct ANSWER: B) Falsely low reading
Rationale: Using a blood pressure cuff that is too large for the patient's arm results in a falsely low
reading because the bladder does not fully compress the brachial artery. Conversely, a cuff that is too
small will produce a falsely high reading. Proper cuff size selection is essential for accurate blood
pressure measurement.
Question 3:
Which diagnostic test is used to detect blood flow within vessels using high-frequency sound waves?
A) Electrocardiogram
B) Chest X-ray
C) Doppler ultrasound
D) Arteriography
Correct ANSWER: C) Doppler ultrasound
Rationale: Doppler ultrasound uses high-frequency sound waves to detect and assess blood flow within
vessels. This noninvasive test is commonly used to evaluate peripheral vascular status, detect deep vein
thrombosis, and assess arterial circulation. It can detect the presence, direction, and velocity of blood
flow.
Question 4:
A patient with a history of diabetes mellitus is having renal function tests due to fatigue and weakness.
Which finding is an early symptom of renal insufficiency?
,A) Dyspnea
B) Nocturia
C) Confusion
D) Stomatitis
Correct ANSWER: B) Nocturia
Rationale: Nocturia (frequent urination during the night) is often an early symptom of renal
insufficiency. As kidney function declines, the kidneys lose their ability to concentrate urine, leading to
increased urine output during the night. Diabetes mellitus is a leading cause of chronic kidney disease,
making this assessment particularly relevant for diabetic patients.
Question 5:
What is the appropriate volume for a hypertonic (Fleet) enema?
A) 30-50 mL
B) 70-130 mL
C) 150-200 mL
D) 500-1000 mL
Correct ANSWER: B) 70-130 mL
Rationale: A hypertonic enema, such as a Fleet enema, typically contains 70-130 mL of solution. The
hypertonic solution draws fluid into the colon through osmosis, stimulating bowel movement. The small
volume makes it appropriate for patients who cannot tolerate large-volume enemas, such as those with
fluid restrictions.
Question 6:
A surgical wound with well-approximated edges and minimal tissue loss is healing by which intention?
A) Primary intention
, B) Secondary intention
C) Tertiary intention
D) Quaternary intention
Correct ANSWER: A) Primary intention
Rationale: Primary intention healing occurs when wound edges are well approximated with minimal
tissue loss, such as in surgical incisions. Healing occurs rapidly with minimal scar formation. This type of
healing involves direct closure of the wound with little granulation tissue formation.
Question 7:
A patient with a large, open wound from a burn injury is healing from the bottom up. This describes
healing by which intention?
A) Primary intention
B) Secondary intention
C) Tertiary intention
D) Delayed primary intention
Correct ANSWER: B) Secondary intention
Rationale: Secondary intention healing occurs in wounds with edges that are not well approximated,
such as burns or major trauma wounds. These wounds heal from the bottom up through granulation
tissue formation, contraction, and epithelialization. Healing is slower and results in more scar tissue
compared to primary intention.
Question 8:
What does red tissue in a healing wound indicate?
A) Necrotic tissue
B) Granulation tissue
Comprehensive Exam 2 - 100 Questions with ANSWERs
and Rationales
Updated for 2025/2026 Curriculum
EXAM QUESTIONS
Question 1:
A patient is placed on contact precautions. Which personal protective equipment (PPE) should the nurse
wear when entering the room?
A) Surgical mask only
B) N95 respirator and gloves
C) Gown and gloves
D) Gown, gloves, and mask
Correct ANSWER: C) Gown and gloves
Rationale: Contact precautions require the use of gown and gloves to prevent transmission of
microorganisms through direct contact with the patient or contaminated environmental surfaces. A
surgical mask is not required for standard contact precautions unless there is a risk of splash or spray.
N95 respirators are reserved for airborne precautions.
Question 2:
The nurse is assessing a patient's blood pressure using a cuff that is too large for the patient's arm. What
effect will this have on the reading?
,A) Falsely high reading
B) Falsely low reading
C) No effect on the reading
D) Unable to obtain a reading
Correct ANSWER: B) Falsely low reading
Rationale: Using a blood pressure cuff that is too large for the patient's arm results in a falsely low
reading because the bladder does not fully compress the brachial artery. Conversely, a cuff that is too
small will produce a falsely high reading. Proper cuff size selection is essential for accurate blood
pressure measurement.
Question 3:
Which diagnostic test is used to detect blood flow within vessels using high-frequency sound waves?
A) Electrocardiogram
B) Chest X-ray
C) Doppler ultrasound
D) Arteriography
Correct ANSWER: C) Doppler ultrasound
Rationale: Doppler ultrasound uses high-frequency sound waves to detect and assess blood flow within
vessels. This noninvasive test is commonly used to evaluate peripheral vascular status, detect deep vein
thrombosis, and assess arterial circulation. It can detect the presence, direction, and velocity of blood
flow.
Question 4:
A patient with a history of diabetes mellitus is having renal function tests due to fatigue and weakness.
Which finding is an early symptom of renal insufficiency?
,A) Dyspnea
B) Nocturia
C) Confusion
D) Stomatitis
Correct ANSWER: B) Nocturia
Rationale: Nocturia (frequent urination during the night) is often an early symptom of renal
insufficiency. As kidney function declines, the kidneys lose their ability to concentrate urine, leading to
increased urine output during the night. Diabetes mellitus is a leading cause of chronic kidney disease,
making this assessment particularly relevant for diabetic patients.
Question 5:
What is the appropriate volume for a hypertonic (Fleet) enema?
A) 30-50 mL
B) 70-130 mL
C) 150-200 mL
D) 500-1000 mL
Correct ANSWER: B) 70-130 mL
Rationale: A hypertonic enema, such as a Fleet enema, typically contains 70-130 mL of solution. The
hypertonic solution draws fluid into the colon through osmosis, stimulating bowel movement. The small
volume makes it appropriate for patients who cannot tolerate large-volume enemas, such as those with
fluid restrictions.
Question 6:
A surgical wound with well-approximated edges and minimal tissue loss is healing by which intention?
A) Primary intention
, B) Secondary intention
C) Tertiary intention
D) Quaternary intention
Correct ANSWER: A) Primary intention
Rationale: Primary intention healing occurs when wound edges are well approximated with minimal
tissue loss, such as in surgical incisions. Healing occurs rapidly with minimal scar formation. This type of
healing involves direct closure of the wound with little granulation tissue formation.
Question 7:
A patient with a large, open wound from a burn injury is healing from the bottom up. This describes
healing by which intention?
A) Primary intention
B) Secondary intention
C) Tertiary intention
D) Delayed primary intention
Correct ANSWER: B) Secondary intention
Rationale: Secondary intention healing occurs in wounds with edges that are not well approximated,
such as burns or major trauma wounds. These wounds heal from the bottom up through granulation
tissue formation, contraction, and epithelialization. Healing is slower and results in more scar tissue
compared to primary intention.
Question 8:
What does red tissue in a healing wound indicate?
A) Necrotic tissue
B) Granulation tissue
