NUR209 — Medical Surgical Nursing II — Comprehensive Review Exam (2026/2027)
NUR209 — Medical Surgical Nursing II
Comprehensive Review Examination
Update — Aligned with QSEN & NCLEX-RN Test Plan
75 Items • Multiple Choice • Cognitive Mix: 30% Recall / 50% Application / 20% Analysis
Instructions: Select the single best response for each item. Scenario-based items require prioritization using the nursing process,
ABC framework, Maslow's hierarchy, and evidence-based practice. High-alert medication items follow ISMP safety standards.
Mark answers on the provided answer sheet. Time allotment: 90 minutes.
Section 1: Cardiovascular & Hematologic Disorders (15 Questions)
Q1: A 68-year-old female with a history of systolic heart failure presents to the ED with acute decompensated
heart failure and pink frothy sputum, orthopnea, and bilateral crackles throughout the lung fields. Oxygen
saturation is 86% on room air. Which intervention should the nurse implement first?
A. Administer IV furosemide 40 mg push over 2 minutes.
B. Place the patient in high-Fowler's position and apply high-flow oxygen via non-rebreather mask.
[CORRECT]
C. Initiate IV nitroglycerin infusion at 10 mcg/min titrated to chest pain.
D. Restrict oral fluid intake to 1,500 mL per day.
Correct Answer: B
Rationale: In acute decompensated heart failure with pulmonary edema, airway and oxygenation take priority (ABC
framework). Positioning the patient in high-Fowler's reduces venous return, decreases preload, and improves ventilation,
while high-flow oxygen addresses the hypoxemia. IV furosemide and nitroglycerin are appropriate subsequent interventions,
but only after oxygenation is established. Fluid restriction is a long-term management strategy, not an acute intervention.
Q2: The provider orders IV furosemide 80 mg for a patient with acute pulmonary edema. Which
administration practice reflects safe nursing care for this high-alert medication?
A. Administer as a rapid IV push over 30 seconds to maximize diuretic effect.
B. Dilute in 100 mL of 0.9% NaCl and infuse over 30 minutes.
C. Administer no faster than 4 mg/minute to reduce the risk of ototoxicity. [CORRECT]
D. Give via intramuscular injection to avoid vein irritation.
Correct Answer: C
Rationale: Per ISMP high-alert medication guidelines, IV furosemide must be administered at a rate no faster than 4
mg/minute (or over 1–2 minutes for doses ≤ 80 mg in patients with normal renal function). Rapid infusion can cause transient
or permanent ototoxicity through direct injury to the stria vascularis of the inner ear. IM administration is not recommended
due to erratic absorption and pain.
Aligned with QSEN competencies and the 2026-2027 NCLEX-RN Test Plan Page 1
,NUR209 — Medical Surgical Nursing II — Comprehensive Review Exam (2026/2027)
Q3: A 74-year-old male receiving oral digoxin 0.25 mg daily and furosemide 40 mg daily for heart failure
reports nausea, vomiting, and yellow-tinged vision. Serum digoxin level is 3.2 ng/mL (therapeutic 0.5–2.0
ng/mL); potassium is 3.0 mEq/L. Which provider order should the nurse anticipate?
A. Administer an additional 0.125 mg digoxin to maintain therapeutic level.
B. Administer IV potassium chloride and continue digoxin at the current dose.
C. Hold digoxin, administer digoxin-specific antibody (Digibind) if indicated, and replace potassium.
[CORRECT]
D. Increase furosemide dose to enhance digoxin excretion.
Correct Answer: C
Rationale: The patient is exhibiting classic digoxin toxicity (GI symptoms, visual disturbances, supratherapeutic level)
compounded by hypokalemia from loop diuretic therapy, which potentiates digoxin toxicity. The correct response is to hold
digoxin immediately, replace potassium, and administer digoxin-specific Fab antibody fragments (Digibind) if
life-threatening dysrhythmias or significant toxicity are present. Increasing diuretics or digoxin would worsen the clinical
condition.
Q4: Which cardiac biomarker is most specific and sensitive for diagnosing acute myocardial infarction within
the first 4 hours of symptom onset?
A. Creatine kinase-MB (CK-MB)
B. Myoglobin
C. Troponin I or T [CORRECT]
D. Lactate dehydrogenase (LDH)
Correct Answer: C
Rationale: Cardiac-specific troponin I and T are the gold-standard biomarkers for diagnosing acute myocardial infarction.
They rise within 3–4 hours of myocardial injury, peak at 10–24 hours, and remain elevated for 7–10 days, providing both
early sensitivity and a wide diagnostic window. CK-MB is less specific (found in skeletal muscle), myoglobin rises early but
lacks cardiac specificity, and LDH is largely obsolete for MI diagnosis due to poor specificity and delayed rise.
Q5: A 59-year-old male arrives at the ED with crushing substernal chest pain, diaphoresis, and ST-segment
elevation in leads II, III, and aVF on the 12-lead ECG. The facility is PCI-capable. According to current
STEMI guidelines, what is the maximum door-to-balloon time goal for primary percutaneous coronary
intervention?
A. 30 minutes
B. 60 minutes
C. 90 minutes [CORRECT]
D. 120 minutes
Correct Answer: C
Rationale: The American Heart Association/American College of Cardiology (AHA/ACC) STEMI guidelines establish a
door-to-balloon time goal of ≤ 90 minutes for primary PCI in PCI-capable facilities. If the patient cannot be transferred for
PCI within 120 minutes of first medical contact, fibrinolytic therapy should be initiated within 30 minutes of arrival
(door-to-needle time). Timely reperfusion is the single most important determinant of mortality reduction in STEMI.
Aligned with QSEN competencies and the 2026-2027 NCLEX-RN Test Plan Page 2
, NUR209 — Medical Surgical Nursing II — Comprehensive Review Exam (2026/2027)
Q6: A patient with a history of uncontrolled hypertension is admitted with a BP of 220/128 mmHg, confusion,
and a new onset of seizures. The diagnosis is hypertensive encephalopathy. Which physiological parameter
should guide the rate of BP reduction in the first hour?
A. Reduce systolic BP to less than 140 mmHg within the first hour.
B. Reduce mean arterial pressure (MAP) by no more than 20–25% in the first hour. [CORRECT]
C. Reduce diastolic BP to less than 80 mmHg within 30 minutes.
D. Maintain current BP to ensure adequate cerebral perfusion pressure.
Correct Answer: B
Rationale: In hypertensive emergency with end-organ damage, BP must be reduced gradually to avoid ischemic injury from
autoregulatory failure. The widely accepted guideline is to reduce MAP by no more than 20–25% within the first hour, then
gradually to 160/100 mmHg over the next 2–6 hours. Rapid normalization of BP can precipitate cerebral, coronary, or renal
hypoperfusion and worsen outcomes.
Q7: A 72-year-old female with new-onset atrial fibrillation is scheduled for electrical cardioversion. Her
CHA2DS2-VASc score is 5. Which interdisciplinary intervention is most appropriate prior to the procedure?
A. Administer IV adenosine 6 mg to chemically cardiovert before electrical cardioversion.
B. Confirm therapeutic anticoagulation for at least 3 weeks or perform TEE to exclude left atrial
thrombus. [CORRECT]
C. Discontinue all anticoagulants 24 hours before the procedure to reduce bleeding risk.
D. Begin oral amiodarone 400 mg daily as a substitute for the cardioversion.
Correct Answer: B
Rationale: For patients with atrial fibrillation of duration > 48 hours or unknown duration and a CHA2DS2-VASc score ≥ 2,
current guidelines require either ≥ 3 weeks of therapeutic anticoagulation prior to cardioversion or exclusion of left atrial
thrombus by transesophageal echocardiogram (TEE) followed by immediate cardioversion. This prevents thromboembolic
stroke from dislodged atrial clot. Anticoagulation should be continued for at least 4 weeks post-cardioversion regardless of
approach.
Q8: A patient on a continuous heparin infusion for a pulmonary embolism develops epistaxis and hematuria.
The aPTT is 110 seconds (control 30 seconds). Which nursing action is the priority?
A. Increase the heparin infusion rate.
B. Stop the heparin infusion and notify the provider; anticipate protamine sulfate. [CORRECT]
C. Apply pressure to the nares and continue the infusion at the same rate.
D. Administer vitamin K intravenously.
Correct Answer: B
Rationale: Active bleeding with a supratherapeutic aPTT (> 2.5× control) on heparin therapy requires immediate
discontinuation of the infusion and provider notification. Protamine sulfate is the specific antidote for unfractionated heparin
and is administered by slow IV push; 1 mg neutralizes approximately 100 units of heparin. Vitamin K is the antidote for
warfarin, not heparin. Continuing the infusion would worsen hemorrhage.
Aligned with QSEN competencies and the 2026-2027 NCLEX-RN Test Plan Page 3
NUR209 — Medical Surgical Nursing II
Comprehensive Review Examination
Update — Aligned with QSEN & NCLEX-RN Test Plan
75 Items • Multiple Choice • Cognitive Mix: 30% Recall / 50% Application / 20% Analysis
Instructions: Select the single best response for each item. Scenario-based items require prioritization using the nursing process,
ABC framework, Maslow's hierarchy, and evidence-based practice. High-alert medication items follow ISMP safety standards.
Mark answers on the provided answer sheet. Time allotment: 90 minutes.
Section 1: Cardiovascular & Hematologic Disorders (15 Questions)
Q1: A 68-year-old female with a history of systolic heart failure presents to the ED with acute decompensated
heart failure and pink frothy sputum, orthopnea, and bilateral crackles throughout the lung fields. Oxygen
saturation is 86% on room air. Which intervention should the nurse implement first?
A. Administer IV furosemide 40 mg push over 2 minutes.
B. Place the patient in high-Fowler's position and apply high-flow oxygen via non-rebreather mask.
[CORRECT]
C. Initiate IV nitroglycerin infusion at 10 mcg/min titrated to chest pain.
D. Restrict oral fluid intake to 1,500 mL per day.
Correct Answer: B
Rationale: In acute decompensated heart failure with pulmonary edema, airway and oxygenation take priority (ABC
framework). Positioning the patient in high-Fowler's reduces venous return, decreases preload, and improves ventilation,
while high-flow oxygen addresses the hypoxemia. IV furosemide and nitroglycerin are appropriate subsequent interventions,
but only after oxygenation is established. Fluid restriction is a long-term management strategy, not an acute intervention.
Q2: The provider orders IV furosemide 80 mg for a patient with acute pulmonary edema. Which
administration practice reflects safe nursing care for this high-alert medication?
A. Administer as a rapid IV push over 30 seconds to maximize diuretic effect.
B. Dilute in 100 mL of 0.9% NaCl and infuse over 30 minutes.
C. Administer no faster than 4 mg/minute to reduce the risk of ototoxicity. [CORRECT]
D. Give via intramuscular injection to avoid vein irritation.
Correct Answer: C
Rationale: Per ISMP high-alert medication guidelines, IV furosemide must be administered at a rate no faster than 4
mg/minute (or over 1–2 minutes for doses ≤ 80 mg in patients with normal renal function). Rapid infusion can cause transient
or permanent ototoxicity through direct injury to the stria vascularis of the inner ear. IM administration is not recommended
due to erratic absorption and pain.
Aligned with QSEN competencies and the 2026-2027 NCLEX-RN Test Plan Page 1
,NUR209 — Medical Surgical Nursing II — Comprehensive Review Exam (2026/2027)
Q3: A 74-year-old male receiving oral digoxin 0.25 mg daily and furosemide 40 mg daily for heart failure
reports nausea, vomiting, and yellow-tinged vision. Serum digoxin level is 3.2 ng/mL (therapeutic 0.5–2.0
ng/mL); potassium is 3.0 mEq/L. Which provider order should the nurse anticipate?
A. Administer an additional 0.125 mg digoxin to maintain therapeutic level.
B. Administer IV potassium chloride and continue digoxin at the current dose.
C. Hold digoxin, administer digoxin-specific antibody (Digibind) if indicated, and replace potassium.
[CORRECT]
D. Increase furosemide dose to enhance digoxin excretion.
Correct Answer: C
Rationale: The patient is exhibiting classic digoxin toxicity (GI symptoms, visual disturbances, supratherapeutic level)
compounded by hypokalemia from loop diuretic therapy, which potentiates digoxin toxicity. The correct response is to hold
digoxin immediately, replace potassium, and administer digoxin-specific Fab antibody fragments (Digibind) if
life-threatening dysrhythmias or significant toxicity are present. Increasing diuretics or digoxin would worsen the clinical
condition.
Q4: Which cardiac biomarker is most specific and sensitive for diagnosing acute myocardial infarction within
the first 4 hours of symptom onset?
A. Creatine kinase-MB (CK-MB)
B. Myoglobin
C. Troponin I or T [CORRECT]
D. Lactate dehydrogenase (LDH)
Correct Answer: C
Rationale: Cardiac-specific troponin I and T are the gold-standard biomarkers for diagnosing acute myocardial infarction.
They rise within 3–4 hours of myocardial injury, peak at 10–24 hours, and remain elevated for 7–10 days, providing both
early sensitivity and a wide diagnostic window. CK-MB is less specific (found in skeletal muscle), myoglobin rises early but
lacks cardiac specificity, and LDH is largely obsolete for MI diagnosis due to poor specificity and delayed rise.
Q5: A 59-year-old male arrives at the ED with crushing substernal chest pain, diaphoresis, and ST-segment
elevation in leads II, III, and aVF on the 12-lead ECG. The facility is PCI-capable. According to current
STEMI guidelines, what is the maximum door-to-balloon time goal for primary percutaneous coronary
intervention?
A. 30 minutes
B. 60 minutes
C. 90 minutes [CORRECT]
D. 120 minutes
Correct Answer: C
Rationale: The American Heart Association/American College of Cardiology (AHA/ACC) STEMI guidelines establish a
door-to-balloon time goal of ≤ 90 minutes for primary PCI in PCI-capable facilities. If the patient cannot be transferred for
PCI within 120 minutes of first medical contact, fibrinolytic therapy should be initiated within 30 minutes of arrival
(door-to-needle time). Timely reperfusion is the single most important determinant of mortality reduction in STEMI.
Aligned with QSEN competencies and the 2026-2027 NCLEX-RN Test Plan Page 2
, NUR209 — Medical Surgical Nursing II — Comprehensive Review Exam (2026/2027)
Q6: A patient with a history of uncontrolled hypertension is admitted with a BP of 220/128 mmHg, confusion,
and a new onset of seizures. The diagnosis is hypertensive encephalopathy. Which physiological parameter
should guide the rate of BP reduction in the first hour?
A. Reduce systolic BP to less than 140 mmHg within the first hour.
B. Reduce mean arterial pressure (MAP) by no more than 20–25% in the first hour. [CORRECT]
C. Reduce diastolic BP to less than 80 mmHg within 30 minutes.
D. Maintain current BP to ensure adequate cerebral perfusion pressure.
Correct Answer: B
Rationale: In hypertensive emergency with end-organ damage, BP must be reduced gradually to avoid ischemic injury from
autoregulatory failure. The widely accepted guideline is to reduce MAP by no more than 20–25% within the first hour, then
gradually to 160/100 mmHg over the next 2–6 hours. Rapid normalization of BP can precipitate cerebral, coronary, or renal
hypoperfusion and worsen outcomes.
Q7: A 72-year-old female with new-onset atrial fibrillation is scheduled for electrical cardioversion. Her
CHA2DS2-VASc score is 5. Which interdisciplinary intervention is most appropriate prior to the procedure?
A. Administer IV adenosine 6 mg to chemically cardiovert before electrical cardioversion.
B. Confirm therapeutic anticoagulation for at least 3 weeks or perform TEE to exclude left atrial
thrombus. [CORRECT]
C. Discontinue all anticoagulants 24 hours before the procedure to reduce bleeding risk.
D. Begin oral amiodarone 400 mg daily as a substitute for the cardioversion.
Correct Answer: B
Rationale: For patients with atrial fibrillation of duration > 48 hours or unknown duration and a CHA2DS2-VASc score ≥ 2,
current guidelines require either ≥ 3 weeks of therapeutic anticoagulation prior to cardioversion or exclusion of left atrial
thrombus by transesophageal echocardiogram (TEE) followed by immediate cardioversion. This prevents thromboembolic
stroke from dislodged atrial clot. Anticoagulation should be continued for at least 4 weeks post-cardioversion regardless of
approach.
Q8: A patient on a continuous heparin infusion for a pulmonary embolism develops epistaxis and hematuria.
The aPTT is 110 seconds (control 30 seconds). Which nursing action is the priority?
A. Increase the heparin infusion rate.
B. Stop the heparin infusion and notify the provider; anticipate protamine sulfate. [CORRECT]
C. Apply pressure to the nares and continue the infusion at the same rate.
D. Administer vitamin K intravenously.
Correct Answer: B
Rationale: Active bleeding with a supratherapeutic aPTT (> 2.5× control) on heparin therapy requires immediate
discontinuation of the infusion and provider notification. Protamine sulfate is the specific antidote for unfractionated heparin
and is administered by slow IV push; 1 mg neutralizes approximately 100 units of heparin. Vitamin K is the antidote for
warfarin, not heparin. Continuing the infusion would worsen hemorrhage.
Aligned with QSEN competencies and the 2026-2027 NCLEX-RN Test Plan Page 3
