NUR209 / NUR 209
Medical-Surgical Nursing II
Comprehensive Review Examination
Latest 2026/2027 Update | Aligned with QSEN Competencies and NCLEX-RN Test Plan
75 Questions | Multiple Choice (A-D) | With Answer Key and Rationales
Section 1: Cardiovascular and Hematologic Disorders (Questions 1-15)
1. A patient with acute decompensated heart failure (ADHF) presents with severe dyspnea, orthopnea, and bilateral
crackles. The nurse anticipates which first-line intravenous diuretic to be administered?
A. Hydrochlorothiazide 25 mg IV
B. Furosemide 40 mg IV push [CORRECT]
C. Spironolactone 50 mg IV
D. Acetazolamide 500 mg IV
Correct Answer: B
Rationale: Furosemide, a loop diuretic, is the first-line IV diuretic for ADHF because it acts on the ascending loop of Henle to promote rapid
diuresis and reduce pulmonary congestion. Hydrochlorothiazide is a thiazide diuretic used for hypertension but is less effective in acute volume
overload. Spironolactone is a potassium-sparing diuretic used as adjunctive therapy in heart failure, not for acute decompensation.
Acetazolamide is a carbonic anhydrase inhibitor rarely used in heart failure management.
2. A patient with pulmonary edema is receiving continuous positive airway pressure (CPAP). Which finding
indicates the intervention is effective?
A. PaO2 decreases from 68 to 55 mmHg
B. Respiratory rate increases from 28 to 36 breaths/min
C. Patient reports decreased dyspnea and SpO2 improves to 94% [CORRECT]
D. Blood pressure drops from 130/80 to 88/50 mmHg
Correct Answer: C
Rationale: CPAP improves oxygenation by maintaining positive pressure throughout the respiratory cycle, keeping alveoli open and reducing
preload and afterload. Effectiveness is demonstrated by improved oxygen saturation, decreased dyspnea, and reduced work of breathing.
Decreasing PaO2 and increasing respiratory rate indicate worsening respiratory status. A significant drop in blood pressure may indicate
excessive reduction in preload, requiring immediate intervention.
Page 1
,NUR209 Medical-Surgical Nursing II - Comprehensive Review Exam 2026/2027 QSEN and NCLEX-RN Aligned
3. The nurse is caring for a patient who underwent percutaneous coronary intervention (PCI) with a femoral artery
approach. Which assessment finding requires immediate intervention?
A. The patient reports mild groin discomfort at the access site
B. The distal pulse on the affected extremity is 2+ and symmetric
C. The access site dressing has a 4 cm expanding hematoma with vital sign changes [CORRECT]
D. The patient has a temperature of 37.8 degrees C (100 degrees F)
Correct Answer: C
Rationale: An expanding hematoma at the femoral access site with associated vital sign changes suggests active bleeding and possible
retroperitoneal hemorrhage, which is a life-threatening complication requiring immediate pressure, notification of the provider, and potential
vascular intervention. Mild discomfort is expected. A 2+ symmetric pulse indicates adequate perfusion. A low-grade fever may be a normal
inflammatory response post-procedure.
4. A patient with heart failure is prescribed enalapril (Vasotec). Which instruction should the nurse prioritize in the
discharge teaching?
A. Rise slowly from sitting or lying positions due to risk of hypotension [CORRECT]
B. Take the medication with high-potassium foods to prevent hypokalemia
C. Expect a persistent dry cough; it is harmless and should be tolerated
D. Discontinue the medication if blood pressure is below 120/80 mmHg
Correct Answer: A
Rationale: ACE inhibitors like enalapril cause vasodilation, leading to orthostatic hypotension. Patients should be taught to change positions
slowly. ACE inhibitors cause potassium retention (hyperkalemia risk), so patients should avoid high-potassium foods, not increase them. While
a dry cough is a known side effect, it should be reported to the provider as it may require switching to an ARB. Medications should never be
abruptly discontinued without provider guidance.
5. A patient with atrial fibrillation is started on warfarin (Coumadin). The nurse understands that which
medication is prescribed concurrently for the first several days to provide immediate anticoagulation?
A. Aspirin 325 mg daily
B. Enoxaparin (Lovenox) subcutaneously [CORRECT]
C. Clopidogrel (Plavix) 75 mg orally
D. Alteplase (tPA) IV infusion
Correct Answer: B
Rationale: Warfarin inhibits synthesis of vitamin K-dependent clotting factors but takes 3 to 5 days to achieve full therapeutic effect. Bridging
therapy with a parenteral anticoagulant such as low-molecular-weight heparin (enoxaparin) or unfractionated heparin provides immediate
anticoagulation until the INR reaches the therapeutic range of 2.0 to 3.0. Aspirin and clopidogrel are antiplatelet agents, not anticoagulants.
Alteplase is a thrombolytic used for acute ischemic stroke and STEMI, not for bridging therapy.
6. A patient with heart failure has a daily weight gain of 2.2 lb (1 kg) over two days. Which action should the nurse
take first?
A. Assess the patient for signs and symptoms of fluid overload [CORRECT]
B. Restrict the patient's fluid intake to 500 mL per day
C. Administer an extra dose of furosemide
D. Document the weight and continue monitoring
Correct Answer: A
Rationale: A weight gain of more than 2 lb (1 kg) in a 24-to-48-hour period is an early indicator of fluid retention in heart failure. The nurse
should first assess for other signs of volume overload, such as jugular venous distention, crackles, edema, and shortness of breath. While fluid
restriction and diuretic adjustment may be needed, these require a provider order and should follow assessment. Merely documenting without
further action delays needed interventions.
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, NUR209 Medical-Surgical Nursing II - Comprehensive Review Exam 2026/2027 QSEN and NCLEX-RN Aligned
7. The nurse is reviewing the laboratory results of a patient with heart failure who is receiving digoxin (Lanoxin).
Which result is most concerning and requires immediate notification of the healthcare provider?
A. Serum potassium level of 3.0 mEq/L [CORRECT]
B. Serum sodium level of 138 mEq/L
C. Serum calcium level of 9.2 mg/dL
D. Serum magnesium level of 2.0 mg/dL
Correct Answer: A
Rationale: Hypokalemia (potassium below 3.5 mEq/L) significantly increases the risk of digoxin toxicity because potassium competes with
digoxin at binding sites on the cardiac muscle. Low potassium enhances digoxin's effect, potentially leading to fatal dysrhythmias. This finding
requires immediate provider notification and potassium replacement. The sodium, calcium, and magnesium values listed are within normal
ranges and do not pose an immediate threat.
8. Which statement by a patient with dilated cardiomyopathy indicates the discharge teaching has been effective?
A. I will restrict my sodium intake to less than 6 grams per day
B. I will weigh myself every morning and report a gain of more than 2 pounds in a day [CORRECT]
C. I will stop taking my carvedilol if my heart rate drops below 70 beats per minute
D. I will drink at least 3 liters of fluid daily to stay hydrated
Correct Answer: B
Rationale: Effective heart failure self-management includes daily weight monitoring with a threshold for reporting. A weight gain of more than 2
to 3 pounds in 24 hours or 5 pounds in a week indicates fluid retention requiring medical evaluation. Sodium restriction should be less than 2 to
3 grams per day, not 6 grams. Beta-blockers like carvedilol should never be abruptly discontinued without provider guidance, even if heart rate
decreases. Fluid intake is typically restricted to 1.5 to 2 liters daily in heart failure.
9. A patient with a deep vein thrombosis (DVT) is receiving heparin therapy. The nurse notes the activated partial
thromboplastin time (aPTT) is 45 seconds with a control of 30 seconds. Which action should the nurse take?
A. Administer the next scheduled dose as ordered
B. Withhold the heparin dose and notify the healthcare provider [CORRECT]
C. Increase the heparin infusion rate by 2 units/kg/hr
D. Administer protamine sulfate as an antidote
Correct Answer: B
Rationale: The therapeutic range for aPTT during heparin therapy is typically 1.5 to 2.5 times the control value. With a control of 30 seconds, the
therapeutic range is 45 to 75 seconds. An aPTT of 45 seconds is at the very low end of the therapeutic range. Many institutional protocols require
the aPTT to be firmly within the therapeutic range before continuing therapy, so the nurse should hold the dose and notify the provider for
adjustment. Protamine sulfate is reserved for heparin overdose with significant bleeding, not for a subtherapeutic aPTT.
10. A patient with chronic heart failure is prescribed spironolactone (Aldactone). Which laboratory value should
the nurse monitor most closely?
A. Serum sodium
B. Serum potassium [CORRECT]
C. Serum chloride
D. Serum calcium
Correct Answer: B
Rationale: Spironolactone is a potassium-sparing diuretic that antagonizes aldosterone, leading to sodium and water excretion while retaining
potassium. Hyperkalemia is the most significant adverse effect and can cause life-threatening cardiac dysrhythmias. The nurse should monitor
serum potassium levels closely, especially when used in combination with ACE inhibitors or ARBs, which also raise potassium levels. While
other electrolytes may be monitored, potassium is the priority.
Page 3
Medical-Surgical Nursing II
Comprehensive Review Examination
Latest 2026/2027 Update | Aligned with QSEN Competencies and NCLEX-RN Test Plan
75 Questions | Multiple Choice (A-D) | With Answer Key and Rationales
Section 1: Cardiovascular and Hematologic Disorders (Questions 1-15)
1. A patient with acute decompensated heart failure (ADHF) presents with severe dyspnea, orthopnea, and bilateral
crackles. The nurse anticipates which first-line intravenous diuretic to be administered?
A. Hydrochlorothiazide 25 mg IV
B. Furosemide 40 mg IV push [CORRECT]
C. Spironolactone 50 mg IV
D. Acetazolamide 500 mg IV
Correct Answer: B
Rationale: Furosemide, a loop diuretic, is the first-line IV diuretic for ADHF because it acts on the ascending loop of Henle to promote rapid
diuresis and reduce pulmonary congestion. Hydrochlorothiazide is a thiazide diuretic used for hypertension but is less effective in acute volume
overload. Spironolactone is a potassium-sparing diuretic used as adjunctive therapy in heart failure, not for acute decompensation.
Acetazolamide is a carbonic anhydrase inhibitor rarely used in heart failure management.
2. A patient with pulmonary edema is receiving continuous positive airway pressure (CPAP). Which finding
indicates the intervention is effective?
A. PaO2 decreases from 68 to 55 mmHg
B. Respiratory rate increases from 28 to 36 breaths/min
C. Patient reports decreased dyspnea and SpO2 improves to 94% [CORRECT]
D. Blood pressure drops from 130/80 to 88/50 mmHg
Correct Answer: C
Rationale: CPAP improves oxygenation by maintaining positive pressure throughout the respiratory cycle, keeping alveoli open and reducing
preload and afterload. Effectiveness is demonstrated by improved oxygen saturation, decreased dyspnea, and reduced work of breathing.
Decreasing PaO2 and increasing respiratory rate indicate worsening respiratory status. A significant drop in blood pressure may indicate
excessive reduction in preload, requiring immediate intervention.
Page 1
,NUR209 Medical-Surgical Nursing II - Comprehensive Review Exam 2026/2027 QSEN and NCLEX-RN Aligned
3. The nurse is caring for a patient who underwent percutaneous coronary intervention (PCI) with a femoral artery
approach. Which assessment finding requires immediate intervention?
A. The patient reports mild groin discomfort at the access site
B. The distal pulse on the affected extremity is 2+ and symmetric
C. The access site dressing has a 4 cm expanding hematoma with vital sign changes [CORRECT]
D. The patient has a temperature of 37.8 degrees C (100 degrees F)
Correct Answer: C
Rationale: An expanding hematoma at the femoral access site with associated vital sign changes suggests active bleeding and possible
retroperitoneal hemorrhage, which is a life-threatening complication requiring immediate pressure, notification of the provider, and potential
vascular intervention. Mild discomfort is expected. A 2+ symmetric pulse indicates adequate perfusion. A low-grade fever may be a normal
inflammatory response post-procedure.
4. A patient with heart failure is prescribed enalapril (Vasotec). Which instruction should the nurse prioritize in the
discharge teaching?
A. Rise slowly from sitting or lying positions due to risk of hypotension [CORRECT]
B. Take the medication with high-potassium foods to prevent hypokalemia
C. Expect a persistent dry cough; it is harmless and should be tolerated
D. Discontinue the medication if blood pressure is below 120/80 mmHg
Correct Answer: A
Rationale: ACE inhibitors like enalapril cause vasodilation, leading to orthostatic hypotension. Patients should be taught to change positions
slowly. ACE inhibitors cause potassium retention (hyperkalemia risk), so patients should avoid high-potassium foods, not increase them. While
a dry cough is a known side effect, it should be reported to the provider as it may require switching to an ARB. Medications should never be
abruptly discontinued without provider guidance.
5. A patient with atrial fibrillation is started on warfarin (Coumadin). The nurse understands that which
medication is prescribed concurrently for the first several days to provide immediate anticoagulation?
A. Aspirin 325 mg daily
B. Enoxaparin (Lovenox) subcutaneously [CORRECT]
C. Clopidogrel (Plavix) 75 mg orally
D. Alteplase (tPA) IV infusion
Correct Answer: B
Rationale: Warfarin inhibits synthesis of vitamin K-dependent clotting factors but takes 3 to 5 days to achieve full therapeutic effect. Bridging
therapy with a parenteral anticoagulant such as low-molecular-weight heparin (enoxaparin) or unfractionated heparin provides immediate
anticoagulation until the INR reaches the therapeutic range of 2.0 to 3.0. Aspirin and clopidogrel are antiplatelet agents, not anticoagulants.
Alteplase is a thrombolytic used for acute ischemic stroke and STEMI, not for bridging therapy.
6. A patient with heart failure has a daily weight gain of 2.2 lb (1 kg) over two days. Which action should the nurse
take first?
A. Assess the patient for signs and symptoms of fluid overload [CORRECT]
B. Restrict the patient's fluid intake to 500 mL per day
C. Administer an extra dose of furosemide
D. Document the weight and continue monitoring
Correct Answer: A
Rationale: A weight gain of more than 2 lb (1 kg) in a 24-to-48-hour period is an early indicator of fluid retention in heart failure. The nurse
should first assess for other signs of volume overload, such as jugular venous distention, crackles, edema, and shortness of breath. While fluid
restriction and diuretic adjustment may be needed, these require a provider order and should follow assessment. Merely documenting without
further action delays needed interventions.
Page 2
, NUR209 Medical-Surgical Nursing II - Comprehensive Review Exam 2026/2027 QSEN and NCLEX-RN Aligned
7. The nurse is reviewing the laboratory results of a patient with heart failure who is receiving digoxin (Lanoxin).
Which result is most concerning and requires immediate notification of the healthcare provider?
A. Serum potassium level of 3.0 mEq/L [CORRECT]
B. Serum sodium level of 138 mEq/L
C. Serum calcium level of 9.2 mg/dL
D. Serum magnesium level of 2.0 mg/dL
Correct Answer: A
Rationale: Hypokalemia (potassium below 3.5 mEq/L) significantly increases the risk of digoxin toxicity because potassium competes with
digoxin at binding sites on the cardiac muscle. Low potassium enhances digoxin's effect, potentially leading to fatal dysrhythmias. This finding
requires immediate provider notification and potassium replacement. The sodium, calcium, and magnesium values listed are within normal
ranges and do not pose an immediate threat.
8. Which statement by a patient with dilated cardiomyopathy indicates the discharge teaching has been effective?
A. I will restrict my sodium intake to less than 6 grams per day
B. I will weigh myself every morning and report a gain of more than 2 pounds in a day [CORRECT]
C. I will stop taking my carvedilol if my heart rate drops below 70 beats per minute
D. I will drink at least 3 liters of fluid daily to stay hydrated
Correct Answer: B
Rationale: Effective heart failure self-management includes daily weight monitoring with a threshold for reporting. A weight gain of more than 2
to 3 pounds in 24 hours or 5 pounds in a week indicates fluid retention requiring medical evaluation. Sodium restriction should be less than 2 to
3 grams per day, not 6 grams. Beta-blockers like carvedilol should never be abruptly discontinued without provider guidance, even if heart rate
decreases. Fluid intake is typically restricted to 1.5 to 2 liters daily in heart failure.
9. A patient with a deep vein thrombosis (DVT) is receiving heparin therapy. The nurse notes the activated partial
thromboplastin time (aPTT) is 45 seconds with a control of 30 seconds. Which action should the nurse take?
A. Administer the next scheduled dose as ordered
B. Withhold the heparin dose and notify the healthcare provider [CORRECT]
C. Increase the heparin infusion rate by 2 units/kg/hr
D. Administer protamine sulfate as an antidote
Correct Answer: B
Rationale: The therapeutic range for aPTT during heparin therapy is typically 1.5 to 2.5 times the control value. With a control of 30 seconds, the
therapeutic range is 45 to 75 seconds. An aPTT of 45 seconds is at the very low end of the therapeutic range. Many institutional protocols require
the aPTT to be firmly within the therapeutic range before continuing therapy, so the nurse should hold the dose and notify the provider for
adjustment. Protamine sulfate is reserved for heparin overdose with significant bleeding, not for a subtherapeutic aPTT.
10. A patient with chronic heart failure is prescribed spironolactone (Aldactone). Which laboratory value should
the nurse monitor most closely?
A. Serum sodium
B. Serum potassium [CORRECT]
C. Serum chloride
D. Serum calcium
Correct Answer: B
Rationale: Spironolactone is a potassium-sparing diuretic that antagonizes aldosterone, leading to sodium and water excretion while retaining
potassium. Hyperkalemia is the most significant adverse effect and can cause life-threatening cardiac dysrhythmias. The nurse should monitor
serum potassium levels closely, especially when used in combination with ACE inhibitors or ARBs, which also raise potassium levels. While
other electrolytes may be monitored, potassium is the priority.
Page 3
