NUR209 / NUR 209 (Latest 2026/2027 Update)
Medical Surgical Nursing II
Comprehensive Review Examination
Aligned with 2026-2027 QSEN Competencies & NCLEX-RN Test Plan
75 Questions | 7 Content Sections | Cognitive Levels: Recall / Application / Analysis
Instructions: Read each question carefully. Select the ONE BEST answer. Each question has four options (A-D) with
exactly one correct response. Answers and rationales follow each question for self-assessment review.
Section 1: Cardiovascular & Hematologic Disorders (Questions 1-15)
Focus: Acute decompensated heart failure, pulmonary edema, anticoagulant therapy, dysrhythmias, hematologic emergencies,
vasoactive medications, prioritization & delegation
Q1: A client with acute decompensated heart failure (ADHF) is admitted with dyspnea at rest, bilateral
crackles, and oxygen saturation of 88% on room air. Which intervention should the nurse implement
FIRST?
A. Administer furosemide 40 mg IV push over 2 minutes
B. Place the client in high-Fowler's position with legs dependent **[CORRECT]**
C. Obtain a 12-lead electrocardiogram (ECG)
D. Prepare for intubation and mechanical ventilation
Correct Answer: B
Rationale: The priority action for a client in acute pulmonary edema is positioning. High-Fowler's position with legs dependent
(dangling) promotes venous pooling in the lower extremities, reducing preload and the volume of blood returning to the heart, which
directly decreases pulmonary congestion. While furosemide, ECG, and possible intubation are all important interventions,
positioning is the first independent nursing action that can be implemented immediately and provides rapid symptom relief. This
follows the airway/breathing/circulation framework and the NCLEX prioritization principle of selecting the least invasive
intervention first.
Q2: The nurse is reviewing the morning laboratory results for a client receiving heparin drip for acute
deep vein thrombosis (DVT). The aPTT is 78 seconds, and the baseline aPTT was 30 seconds. The
prescribed aPTT range is 1.5-2.5 times the baseline. Which action should the nurse take?
A. Increase the heparin drip rate by 2 units/kg/hr as prescribed
B. Stop the heparin drip immediately and prepare to administer protamine sulfate
C. No change is needed; the aPTT is within the therapeutic range **[CORRECT]**
D. Decrease the heparin drip rate by 1 unit/kg/hr and recheck in 4 hours
Correct Answer: C
Rationale: The therapeutic range for aPTT when treating DVT with heparin is 1.5 to 2.5 times the baseline value. The client's
baseline is 30 seconds, making the therapeutic range 45 to 75 seconds. An aPTT of 78 seconds is very close to the upper limit (2.5 x
30 = 75) and falls within the 10% tolerance range that many institutions accept. It does not require stopping heparin and
administering protamine sulfate, which is reserved for significant overdosage with active bleeding. A small rate reduction could be
considered, but many facilities would consider this within acceptable therapeutic limits for continued monitoring without a rate
change. The nurse should continue to monitor and recheck the aPTT at the prescribed interval.
NUR209 Medical Surgical Nursing II Comprehensive Review | Page 1
,Q3: Which laboratory value is the most reliable indicator of renal function when monitoring a client who is
receiving digoxin (Lanoxin) therapy?
A. Blood urea nitrogen (BUN)
B. Serum creatinine
C. Glomerular filtration rate (GFR) **[CORRECT]**
D. Serum potassium
Correct Answer: C
Rationale: The glomerular filtration rate (GFR) is the most reliable and accurate indicator of renal function. Digoxin is primarily
eliminated by the kidneys, and renal impairment is the most significant risk factor for digoxin toxicity. While serum creatinine and
BUN are commonly used markers, they are less sensitive than GFR, especially in elderly clients whose muscle mass (and thus
creatinine production) may be reduced. The GFR provides a direct measure of the kidneys' filtering capacity and is used to calculate
drug dosing adjustments. Monitoring GFR allows the nurse and provider to anticipate the need for digoxin dose reduction before
toxicity occurs, which is a critical safety consideration for this narrow therapeutic index medication.
Q4: A client with heart failure is prescribed enalapril (Vasotec) and spironolactone (Aldactone). The nurse
should monitor the client for which potential adverse effect of this medication combination?
A. Hyperkalemia **[CORRECT]**
B. Hypokalemia
C. Hypernatremia
D. Hypocalcemia
Correct Answer: A
Rationale: Both enalapril (an ACE inhibitor) and spironolactone (a potassium-sparing diuretic) can cause potassium retention.
ACE inhibitors decrease aldosterone production, which normally promotes potassium excretion, and spironolactone directly blocks
aldosterone receptors in the distal tubule. When combined, these medications have a synergistic effect on potassium retention,
creating a significant risk for hyperkalemia. The nurse should monitor serum potassium levels closely, assess for signs of
hyperkalemia (muscle weakness, paresthesias, dysrhythmias), and educate the client to avoid potassium-rich foods and salt
substitutes containing potassium chloride. This combination is a guideline-recommended therapy for heart failure (ACEI plus
aldosterone antagonist) but requires vigilant potassium monitoring.
Q5: The nurse receives morning report on four clients with cardiovascular diagnoses. Which client should
the nurse assess FIRST?
A. A client with chronic stable angina who reports mild chest discomfort after walking to the bathroom
B. A client with atrial fibrillation on warfarin therapy whose INR is 3.2
C. A client with heart failure who gained 2.2 kg (4.8 lb) overnight and has new-onset dyspnea at rest
**[CORRECT]**
D. A client 2 days post-cardiac catheterization whose puncture site has a small ecchymosis of 2 cm
Correct Answer: C
Rationale: The client with heart failure who gained 2.2 kg overnight with new-onset dyspnea at rest requires immediate assessment.
A weight gain of more than 1-2 kg in 24 hours indicates significant fluid retention, suggesting acute decompensation of heart failure.
New-onset dyspnea at rest is a sign of pulmonary edema, which is a medical emergency. This client is at the highest risk for
respiratory compromise and requires urgent intervention including diuretic therapy, oxygen, and potentially vasodilator
administration. While the other clients need monitoring, their findings are either expected (small ecchymosis post-catheterization),
stable (INR 3.2 is slightly above the typical 2.0-3.0 range but not critical), or less acute (stable angina with mild discomfort after
exertion).
Q6: A client is admitted with a suspected acute myocardial infarction (MI). The 12-lead ECG reveals
ST-segment elevation in leads II, III, and aVF. The nurse should anticipate which immediate intervention?
A. Administration of clopidogrel (Plavix) 75 mg orally
NUR209 Medical Surgical Nursing II Comprehensive Review | Page 2
, B. Initiation of fibrinolytic therapy or percutaneous coronary intervention (PCI) **[CORRECT]**
C. Insertion of a temporary pacemaker
D. Administration of digoxin (Lanoxin) IV to improve cardiac output
Correct Answer: B
Rationale: ST-segment elevation in leads II, III, and aVF indicates an inferior wall myocardial infarction. The presence of ST
elevation on ECG confirms a STEMI, which requires immediate reperfusion therapy, either through fibrinolytic administration (if
PCI is not available within the recommended timeframe) or primary percutaneous coronary intervention (PCI), which is the
preferred treatment. The goal is to restore coronary blood flow as quickly as possible, ideally within 90 minutes of first medical
contact for PCI or 30 minutes for fibrinolytics (door-to-needle time). Clopidogrel will be given as adjunctive therapy but is not the
immediate priority. Digoxin is contraindicated in acute MI. Temporary pacing may be needed later for inferior MI due to right
coronary artery involvement affecting the conduction system, but reperfusion is the first priority.
Q7: A client with iron deficiency anemia is prescribed oral ferrous sulfate. Which instruction should the
nurse include in the discharge teaching?
A. Take the medication on an empty stomach with a glass of milk for better absorption
B. Expect stools to turn dark green or black, which is a harmless side effect **[CORRECT]**
C. Take the medication with antacids to reduce gastrointestinal distress
D. Limit vitamin C intake because it interferes with iron absorption
Correct Answer: B
Rationale: Dark green or black stools are a common and expected side effect of oral iron therapy. The nurse should inform the
client about this to prevent unnecessary alarm. Iron is best absorbed on an empty stomach, but taking it with meals may reduce GI
upset; however, milk and antacids decrease iron absorption because calcium and alkaline environments interfere with iron uptake.
Vitamin C (ascorbic acid) actually enhances iron absorption and should be taken concurrently with iron supplements. Therefore, the
client should be advised to take iron with vitamin C-rich juice (like orange juice) and avoid taking it with milk, antacids, or calcium
supplements. This education is essential for therapeutic effectiveness.
Q8: The charge nurse is making client assignments on a cardiac step-down unit. Which task is MOST
appropriate to delegate to an unlicensed assistive personnel (UAP)?
A. Assessing a client's cardiac rhythm on the telemetry monitor
B. Measuring vital signs and reporting the results to the registered nurse **[CORRECT]**
C. Educating a client about a new prescribed anticoagulant medication
D. Evaluating a client's understanding of dietary sodium restrictions
Correct Answer: B
Rationale: Measuring vital signs and reporting results to the registered nurse is within the scope of practice for unlicensed assistive
personnel (UAP). The UAP can obtain measurements such as blood pressure, heart rate, respiratory rate, temperature, and oxygen
saturation, and then report these findings to the RN for interpretation and clinical decision-making. Assessing cardiac rhythms on
telemetry, providing medication education, and evaluating client understanding of dietary restrictions all require the clinical
judgment, knowledge, and scope of practice of a licensed registered nurse. Delegation principles require that the RN retains
assessment, teaching, and evaluation tasks while assigning routine, repetitive tasks that do not require nursing judgment to
appropriately trained UAP.
Q9: A client with heart failure is receiving intravenous nitroglycerin (Tridil) at 50 mcg/min. The nurse
notes the client's blood pressure has dropped from 118/72 mmHg to 82/50 mmHg. What is the priority
nursing action?
A. Administer a 500 mL normal saline fluid bolus
B. Reduce the nitroglycerin infusion rate and reassess blood pressure in 5 minutes **[CORRECT]**
C. Document the findings and continue monitoring at the current rate
D. Obtain a stat 12-lead ECG to assess for myocardial ischemia
NUR209 Medical Surgical Nursing II Comprehensive Review | Page 3
Medical Surgical Nursing II
Comprehensive Review Examination
Aligned with 2026-2027 QSEN Competencies & NCLEX-RN Test Plan
75 Questions | 7 Content Sections | Cognitive Levels: Recall / Application / Analysis
Instructions: Read each question carefully. Select the ONE BEST answer. Each question has four options (A-D) with
exactly one correct response. Answers and rationales follow each question for self-assessment review.
Section 1: Cardiovascular & Hematologic Disorders (Questions 1-15)
Focus: Acute decompensated heart failure, pulmonary edema, anticoagulant therapy, dysrhythmias, hematologic emergencies,
vasoactive medications, prioritization & delegation
Q1: A client with acute decompensated heart failure (ADHF) is admitted with dyspnea at rest, bilateral
crackles, and oxygen saturation of 88% on room air. Which intervention should the nurse implement
FIRST?
A. Administer furosemide 40 mg IV push over 2 minutes
B. Place the client in high-Fowler's position with legs dependent **[CORRECT]**
C. Obtain a 12-lead electrocardiogram (ECG)
D. Prepare for intubation and mechanical ventilation
Correct Answer: B
Rationale: The priority action for a client in acute pulmonary edema is positioning. High-Fowler's position with legs dependent
(dangling) promotes venous pooling in the lower extremities, reducing preload and the volume of blood returning to the heart, which
directly decreases pulmonary congestion. While furosemide, ECG, and possible intubation are all important interventions,
positioning is the first independent nursing action that can be implemented immediately and provides rapid symptom relief. This
follows the airway/breathing/circulation framework and the NCLEX prioritization principle of selecting the least invasive
intervention first.
Q2: The nurse is reviewing the morning laboratory results for a client receiving heparin drip for acute
deep vein thrombosis (DVT). The aPTT is 78 seconds, and the baseline aPTT was 30 seconds. The
prescribed aPTT range is 1.5-2.5 times the baseline. Which action should the nurse take?
A. Increase the heparin drip rate by 2 units/kg/hr as prescribed
B. Stop the heparin drip immediately and prepare to administer protamine sulfate
C. No change is needed; the aPTT is within the therapeutic range **[CORRECT]**
D. Decrease the heparin drip rate by 1 unit/kg/hr and recheck in 4 hours
Correct Answer: C
Rationale: The therapeutic range for aPTT when treating DVT with heparin is 1.5 to 2.5 times the baseline value. The client's
baseline is 30 seconds, making the therapeutic range 45 to 75 seconds. An aPTT of 78 seconds is very close to the upper limit (2.5 x
30 = 75) and falls within the 10% tolerance range that many institutions accept. It does not require stopping heparin and
administering protamine sulfate, which is reserved for significant overdosage with active bleeding. A small rate reduction could be
considered, but many facilities would consider this within acceptable therapeutic limits for continued monitoring without a rate
change. The nurse should continue to monitor and recheck the aPTT at the prescribed interval.
NUR209 Medical Surgical Nursing II Comprehensive Review | Page 1
,Q3: Which laboratory value is the most reliable indicator of renal function when monitoring a client who is
receiving digoxin (Lanoxin) therapy?
A. Blood urea nitrogen (BUN)
B. Serum creatinine
C. Glomerular filtration rate (GFR) **[CORRECT]**
D. Serum potassium
Correct Answer: C
Rationale: The glomerular filtration rate (GFR) is the most reliable and accurate indicator of renal function. Digoxin is primarily
eliminated by the kidneys, and renal impairment is the most significant risk factor for digoxin toxicity. While serum creatinine and
BUN are commonly used markers, they are less sensitive than GFR, especially in elderly clients whose muscle mass (and thus
creatinine production) may be reduced. The GFR provides a direct measure of the kidneys' filtering capacity and is used to calculate
drug dosing adjustments. Monitoring GFR allows the nurse and provider to anticipate the need for digoxin dose reduction before
toxicity occurs, which is a critical safety consideration for this narrow therapeutic index medication.
Q4: A client with heart failure is prescribed enalapril (Vasotec) and spironolactone (Aldactone). The nurse
should monitor the client for which potential adverse effect of this medication combination?
A. Hyperkalemia **[CORRECT]**
B. Hypokalemia
C. Hypernatremia
D. Hypocalcemia
Correct Answer: A
Rationale: Both enalapril (an ACE inhibitor) and spironolactone (a potassium-sparing diuretic) can cause potassium retention.
ACE inhibitors decrease aldosterone production, which normally promotes potassium excretion, and spironolactone directly blocks
aldosterone receptors in the distal tubule. When combined, these medications have a synergistic effect on potassium retention,
creating a significant risk for hyperkalemia. The nurse should monitor serum potassium levels closely, assess for signs of
hyperkalemia (muscle weakness, paresthesias, dysrhythmias), and educate the client to avoid potassium-rich foods and salt
substitutes containing potassium chloride. This combination is a guideline-recommended therapy for heart failure (ACEI plus
aldosterone antagonist) but requires vigilant potassium monitoring.
Q5: The nurse receives morning report on four clients with cardiovascular diagnoses. Which client should
the nurse assess FIRST?
A. A client with chronic stable angina who reports mild chest discomfort after walking to the bathroom
B. A client with atrial fibrillation on warfarin therapy whose INR is 3.2
C. A client with heart failure who gained 2.2 kg (4.8 lb) overnight and has new-onset dyspnea at rest
**[CORRECT]**
D. A client 2 days post-cardiac catheterization whose puncture site has a small ecchymosis of 2 cm
Correct Answer: C
Rationale: The client with heart failure who gained 2.2 kg overnight with new-onset dyspnea at rest requires immediate assessment.
A weight gain of more than 1-2 kg in 24 hours indicates significant fluid retention, suggesting acute decompensation of heart failure.
New-onset dyspnea at rest is a sign of pulmonary edema, which is a medical emergency. This client is at the highest risk for
respiratory compromise and requires urgent intervention including diuretic therapy, oxygen, and potentially vasodilator
administration. While the other clients need monitoring, their findings are either expected (small ecchymosis post-catheterization),
stable (INR 3.2 is slightly above the typical 2.0-3.0 range but not critical), or less acute (stable angina with mild discomfort after
exertion).
Q6: A client is admitted with a suspected acute myocardial infarction (MI). The 12-lead ECG reveals
ST-segment elevation in leads II, III, and aVF. The nurse should anticipate which immediate intervention?
A. Administration of clopidogrel (Plavix) 75 mg orally
NUR209 Medical Surgical Nursing II Comprehensive Review | Page 2
, B. Initiation of fibrinolytic therapy or percutaneous coronary intervention (PCI) **[CORRECT]**
C. Insertion of a temporary pacemaker
D. Administration of digoxin (Lanoxin) IV to improve cardiac output
Correct Answer: B
Rationale: ST-segment elevation in leads II, III, and aVF indicates an inferior wall myocardial infarction. The presence of ST
elevation on ECG confirms a STEMI, which requires immediate reperfusion therapy, either through fibrinolytic administration (if
PCI is not available within the recommended timeframe) or primary percutaneous coronary intervention (PCI), which is the
preferred treatment. The goal is to restore coronary blood flow as quickly as possible, ideally within 90 minutes of first medical
contact for PCI or 30 minutes for fibrinolytics (door-to-needle time). Clopidogrel will be given as adjunctive therapy but is not the
immediate priority. Digoxin is contraindicated in acute MI. Temporary pacing may be needed later for inferior MI due to right
coronary artery involvement affecting the conduction system, but reperfusion is the first priority.
Q7: A client with iron deficiency anemia is prescribed oral ferrous sulfate. Which instruction should the
nurse include in the discharge teaching?
A. Take the medication on an empty stomach with a glass of milk for better absorption
B. Expect stools to turn dark green or black, which is a harmless side effect **[CORRECT]**
C. Take the medication with antacids to reduce gastrointestinal distress
D. Limit vitamin C intake because it interferes with iron absorption
Correct Answer: B
Rationale: Dark green or black stools are a common and expected side effect of oral iron therapy. The nurse should inform the
client about this to prevent unnecessary alarm. Iron is best absorbed on an empty stomach, but taking it with meals may reduce GI
upset; however, milk and antacids decrease iron absorption because calcium and alkaline environments interfere with iron uptake.
Vitamin C (ascorbic acid) actually enhances iron absorption and should be taken concurrently with iron supplements. Therefore, the
client should be advised to take iron with vitamin C-rich juice (like orange juice) and avoid taking it with milk, antacids, or calcium
supplements. This education is essential for therapeutic effectiveness.
Q8: The charge nurse is making client assignments on a cardiac step-down unit. Which task is MOST
appropriate to delegate to an unlicensed assistive personnel (UAP)?
A. Assessing a client's cardiac rhythm on the telemetry monitor
B. Measuring vital signs and reporting the results to the registered nurse **[CORRECT]**
C. Educating a client about a new prescribed anticoagulant medication
D. Evaluating a client's understanding of dietary sodium restrictions
Correct Answer: B
Rationale: Measuring vital signs and reporting results to the registered nurse is within the scope of practice for unlicensed assistive
personnel (UAP). The UAP can obtain measurements such as blood pressure, heart rate, respiratory rate, temperature, and oxygen
saturation, and then report these findings to the RN for interpretation and clinical decision-making. Assessing cardiac rhythms on
telemetry, providing medication education, and evaluating client understanding of dietary restrictions all require the clinical
judgment, knowledge, and scope of practice of a licensed registered nurse. Delegation principles require that the RN retains
assessment, teaching, and evaluation tasks while assigning routine, repetitive tasks that do not require nursing judgment to
appropriately trained UAP.
Q9: A client with heart failure is receiving intravenous nitroglycerin (Tridil) at 50 mcg/min. The nurse
notes the client's blood pressure has dropped from 118/72 mmHg to 82/50 mmHg. What is the priority
nursing action?
A. Administer a 500 mL normal saline fluid bolus
B. Reduce the nitroglycerin infusion rate and reassess blood pressure in 5 minutes **[CORRECT]**
C. Document the findings and continue monitoring at the current rate
D. Obtain a stat 12-lead ECG to assess for myocardial ischemia
NUR209 Medical Surgical Nursing II Comprehensive Review | Page 3
