,NUR 209 Final Exam | Medical - Surgical Nursing II (2026) Actual Q&A
PDF | Fortis College
1. A nurse is caring for a patient who is experiencing an acute myocardial infarction.
Which assessment finding requires immediate intervention?
A) Pain rated 4/10
B) Heart rate of 92 beats/min
C) New onset of crackles and dyspnea
D) Blood pressure of 110/70 mm Hg
Correct Answer: New onset of crackles and dyspnea
Rationale: New crackles and dyspnea after myocardial infarction suggest the
development of heart failure or pulmonary edema, requiring immediate intervention.
Mild pain, a heart rate of 92, and a blood pressure of 110/70 are within acceptable
limits. Prompt assessme nt and treatment can prevent further deterioration.
2. A patient with heart failure is prescribed furosemide. Which laboratory value
should the nurse monitor most closely?
A) Serum sodium
B) Serum potassium
C) Serum calcium
D) Serum magnesium
Correct Answer: Serum potassium
Rationale: Furosemide is a loop diuretic that increases potassium excretion,
leading to hypokalemia. Monitoring serum potassium is essential to prevent cardiac
,dysrhythmias. Sodium, calcium, and magnesium are important but are not the
primary electrolytes affected by furosemide.
3. Which finding indicates a need for immediate intervention in a patient receiving
heparin therapy?
A) INR of 2.5
B) Platelet count of 150,000/mm³
C) Sudden onset of back pain and hypotension
D) Bruise at the injection site
Correct Answer: Sudden onset of back pain and hypotension
Rationale: Sudden back pain and hypotension may indicate retroperitoneal
bleeding, a serious complication of heparin therapy. An INR of 2.5 is therapeutic for
warfarin, not heparin. A platelet count of 150,000/mm³ is within normal limits, and a
bruise at the injecti on site is expected.
4. Which laboratory value should the nurse monitor to evaluate the effectiveness of
warfarin therapy?
A) Platelet count
B) INR
C) aPTT
D) Hemoglobin
Correct Answer: INR
Rationale: Warfarin therapy is monitored using the International Normalized Ratio,
with a therapeutic range typically between 2.0 and 3.0. Platelet count assesses
, clotting ability but not warfarin effectiveness. aPTT monitors heparin therapy, and
hemoglobin assesses oxygen - carrying capacity.
5. Which patient should the nurse assess first?
A) A patient requesting pain medication for a headache
B) A patient with new - onset shortness of breath and oxygen saturation of 88%
C) A patient who needs assistance with ambulation to the bathroom
D) A patient asking questions about discharge instructions
Correct Answer: A patient with new - onset shortness of breath and oxygen
saturation of 88%
Rationale: Using the ABCs (airway, breathing, circulation) and Maslow's hierarchy,
the patient with acute respiratory distress and low oxygen saturation requires
immediate assessment and intervention. Pain, ambulation assistance, and
discharge questions are importan t but not life - threatening priorities. Prioritization
is a key nursing skill.
6. Which statement best describes the purpose of the nursing process?
A) A linear checklist completed once per shift
B) A systematic, ongoing framework for delivering patient - centered care
C) A tool used exclusively by physicians to diagnose disease
D) A method for documenting care solely for reimbursement
Correct Answer: A systematic, ongoing framework for delivering patient -
centered care
PDF | Fortis College
1. A nurse is caring for a patient who is experiencing an acute myocardial infarction.
Which assessment finding requires immediate intervention?
A) Pain rated 4/10
B) Heart rate of 92 beats/min
C) New onset of crackles and dyspnea
D) Blood pressure of 110/70 mm Hg
Correct Answer: New onset of crackles and dyspnea
Rationale: New crackles and dyspnea after myocardial infarction suggest the
development of heart failure or pulmonary edema, requiring immediate intervention.
Mild pain, a heart rate of 92, and a blood pressure of 110/70 are within acceptable
limits. Prompt assessme nt and treatment can prevent further deterioration.
2. A patient with heart failure is prescribed furosemide. Which laboratory value
should the nurse monitor most closely?
A) Serum sodium
B) Serum potassium
C) Serum calcium
D) Serum magnesium
Correct Answer: Serum potassium
Rationale: Furosemide is a loop diuretic that increases potassium excretion,
leading to hypokalemia. Monitoring serum potassium is essential to prevent cardiac
,dysrhythmias. Sodium, calcium, and magnesium are important but are not the
primary electrolytes affected by furosemide.
3. Which finding indicates a need for immediate intervention in a patient receiving
heparin therapy?
A) INR of 2.5
B) Platelet count of 150,000/mm³
C) Sudden onset of back pain and hypotension
D) Bruise at the injection site
Correct Answer: Sudden onset of back pain and hypotension
Rationale: Sudden back pain and hypotension may indicate retroperitoneal
bleeding, a serious complication of heparin therapy. An INR of 2.5 is therapeutic for
warfarin, not heparin. A platelet count of 150,000/mm³ is within normal limits, and a
bruise at the injecti on site is expected.
4. Which laboratory value should the nurse monitor to evaluate the effectiveness of
warfarin therapy?
A) Platelet count
B) INR
C) aPTT
D) Hemoglobin
Correct Answer: INR
Rationale: Warfarin therapy is monitored using the International Normalized Ratio,
with a therapeutic range typically between 2.0 and 3.0. Platelet count assesses
, clotting ability but not warfarin effectiveness. aPTT monitors heparin therapy, and
hemoglobin assesses oxygen - carrying capacity.
5. Which patient should the nurse assess first?
A) A patient requesting pain medication for a headache
B) A patient with new - onset shortness of breath and oxygen saturation of 88%
C) A patient who needs assistance with ambulation to the bathroom
D) A patient asking questions about discharge instructions
Correct Answer: A patient with new - onset shortness of breath and oxygen
saturation of 88%
Rationale: Using the ABCs (airway, breathing, circulation) and Maslow's hierarchy,
the patient with acute respiratory distress and low oxygen saturation requires
immediate assessment and intervention. Pain, ambulation assistance, and
discharge questions are importan t but not life - threatening priorities. Prioritization
is a key nursing skill.
6. Which statement best describes the purpose of the nursing process?
A) A linear checklist completed once per shift
B) A systematic, ongoing framework for delivering patient - centered care
C) A tool used exclusively by physicians to diagnose disease
D) A method for documenting care solely for reimbursement
Correct Answer: A systematic, ongoing framework for delivering patient -
centered care
