NUR 2502 Final Exam: Multidimensional Care III (MDC
3) Verified and Updated Questions and Answers
1. A patient with heart failure is complaining of sudden shortness of breath and
has crackles in the lung bases. Which type of heart failure does the nurse
suspect?
A. Left-sided heart failure
B. Right-sided heart failure
C. High-output heart failure
D. Systolic heart failure with peripheral edema
Answer: A
Explanation: Left-sided heart failure leads to pulmonary congestion, which manifests as
crackles, dyspnea, and orthopnea.
2. Which assessment finding is most characteristic of a patient experiencing
right-sided heart failure?
A. Pulmonary edema
B. Pink, frothy sputum
C. Dry, hacking cough
D. Jugular venous distension (JVD)
Answer: D
Explanation: Right-sided heart failure causes blood to back up into the systemic
circulation, leading to JVD, peripheral edema, and hepatomegaly.
,3. A nurse is caring for a patient with atrial fibrillation. What is the primary risk
associated with this dysrhythmia?
A. Cardiac arrest
B. Thrombus formation and stroke
C. Pulmonary hypertension
D. Ventricular tachycardia
Answer: B
Explanation: Atrial fibrillation results in blood stasis in the atria, significantly increasing
the risk of blood clots traveling to the brain and causing a stroke.
4. A patient’s EKG shows Ventricular Fibrillation. Which action should the nurse
take first?
A. Administer Atropine IV
B. Check for a pulse for 1 minute
C. Start an Amiodarone drip
D. Perform immediate defibrillation
Answer: D
Explanation: Ventricular fibrillation is a lethal rhythm that requires immediate
defibrillation to restore a perfusing rhythm.
5. The nurse is assessing a patient in hypovolemic shock. Which finding should
the nurse anticipate?
A. Bradycardia and hypertension
B. Bounding pulses and warm skin
C. Tachycardia and hypotension
D. Increased urine output
Answer: C
Explanation: Hypovolemic shock results in low circulating volume, leading to
compensatory tachycardia and low blood pressure.
,6. Which laboratory value is the best indicator of tissue perfusion in a patient
with septic shock?
A. White blood cell count
B. Blood urea nitrogen (BUN)
C. Hemoglobin
D. Serum lactate level
Answer: D
Explanation: Lactate levels increase when tissues do not receive enough oxygen, leading to
anaerobic metabolism; thus, it is a key marker for shock severity.
7. A patient with burns to the entire left arm and the anterior trunk is being
evaluated. Using the Rule of Nines, what is the estimated total body surface
area (TBSA) burned?
A. 18%
B. 27%
C. 36%
D. 45%
Answer: B
Explanation: The left arm is 9% and the anterior trunk is 18%, totaling 27% TBSA.
8. During the resuscitation phase of a burn injury, which electrolyte abnormality
is the nurse most likely to observe?
A. Hypokalemia
B. Hyperkalemia
C. Hypercalcemia
D. Hypernatremia
Answer: B
Explanation: Cell destruction in burns releases potassium into the extracellular space,
leading to hyperkalemia during the first 24-48 hours.
, 9. A patient is admitted with Acute Kidney Injury (AKI) and has a serum
potassium level of 6.8 mEq/L. Which medication should the nurse be prepared
to administer to stabilize the heart?
A. Calcium Gluconate
B. Sodium Polystyrene Sulfonate
C. Furosemide
D. Lisinopril
Answer: A
Explanation: Calcium gluconate does not lower potassium, but it protects the heart
(myocardium) from the lethal effects of hyperkalemia.
10. The nurse is monitoring a patient with a head injury. Which set of vital signs
represents Cushing’s Triad, indicating increased intracranial pressure (ICP)?
A. BP 90/60, HR 120, tachypnea
B. BP 180/60, HR 50, irregular respirations
C. BP 120/80, HR 70, normal respirations
D. BP 110/70, HR 100, shallow respirations
Answer: B
Explanation: Cushing’s Triad consists of widened pulse pressure (systolic hypertension),
bradycardia, and irregular/slow respirations.
11. A patient on a mechanical ventilator has a high-pressure alarm sounding.
What is a common cause for this alarm?
A. Disconnection of the tubing
B. A leak in the ET tube cuff
C. Extubation
D. Patient biting the ET tube
Answer: D
3) Verified and Updated Questions and Answers
1. A patient with heart failure is complaining of sudden shortness of breath and
has crackles in the lung bases. Which type of heart failure does the nurse
suspect?
A. Left-sided heart failure
B. Right-sided heart failure
C. High-output heart failure
D. Systolic heart failure with peripheral edema
Answer: A
Explanation: Left-sided heart failure leads to pulmonary congestion, which manifests as
crackles, dyspnea, and orthopnea.
2. Which assessment finding is most characteristic of a patient experiencing
right-sided heart failure?
A. Pulmonary edema
B. Pink, frothy sputum
C. Dry, hacking cough
D. Jugular venous distension (JVD)
Answer: D
Explanation: Right-sided heart failure causes blood to back up into the systemic
circulation, leading to JVD, peripheral edema, and hepatomegaly.
,3. A nurse is caring for a patient with atrial fibrillation. What is the primary risk
associated with this dysrhythmia?
A. Cardiac arrest
B. Thrombus formation and stroke
C. Pulmonary hypertension
D. Ventricular tachycardia
Answer: B
Explanation: Atrial fibrillation results in blood stasis in the atria, significantly increasing
the risk of blood clots traveling to the brain and causing a stroke.
4. A patient’s EKG shows Ventricular Fibrillation. Which action should the nurse
take first?
A. Administer Atropine IV
B. Check for a pulse for 1 minute
C. Start an Amiodarone drip
D. Perform immediate defibrillation
Answer: D
Explanation: Ventricular fibrillation is a lethal rhythm that requires immediate
defibrillation to restore a perfusing rhythm.
5. The nurse is assessing a patient in hypovolemic shock. Which finding should
the nurse anticipate?
A. Bradycardia and hypertension
B. Bounding pulses and warm skin
C. Tachycardia and hypotension
D. Increased urine output
Answer: C
Explanation: Hypovolemic shock results in low circulating volume, leading to
compensatory tachycardia and low blood pressure.
,6. Which laboratory value is the best indicator of tissue perfusion in a patient
with septic shock?
A. White blood cell count
B. Blood urea nitrogen (BUN)
C. Hemoglobin
D. Serum lactate level
Answer: D
Explanation: Lactate levels increase when tissues do not receive enough oxygen, leading to
anaerobic metabolism; thus, it is a key marker for shock severity.
7. A patient with burns to the entire left arm and the anterior trunk is being
evaluated. Using the Rule of Nines, what is the estimated total body surface
area (TBSA) burned?
A. 18%
B. 27%
C. 36%
D. 45%
Answer: B
Explanation: The left arm is 9% and the anterior trunk is 18%, totaling 27% TBSA.
8. During the resuscitation phase of a burn injury, which electrolyte abnormality
is the nurse most likely to observe?
A. Hypokalemia
B. Hyperkalemia
C. Hypercalcemia
D. Hypernatremia
Answer: B
Explanation: Cell destruction in burns releases potassium into the extracellular space,
leading to hyperkalemia during the first 24-48 hours.
, 9. A patient is admitted with Acute Kidney Injury (AKI) and has a serum
potassium level of 6.8 mEq/L. Which medication should the nurse be prepared
to administer to stabilize the heart?
A. Calcium Gluconate
B. Sodium Polystyrene Sulfonate
C. Furosemide
D. Lisinopril
Answer: A
Explanation: Calcium gluconate does not lower potassium, but it protects the heart
(myocardium) from the lethal effects of hyperkalemia.
10. The nurse is monitoring a patient with a head injury. Which set of vital signs
represents Cushing’s Triad, indicating increased intracranial pressure (ICP)?
A. BP 90/60, HR 120, tachypnea
B. BP 180/60, HR 50, irregular respirations
C. BP 120/80, HR 70, normal respirations
D. BP 110/70, HR 100, shallow respirations
Answer: B
Explanation: Cushing’s Triad consists of widened pulse pressure (systolic hypertension),
bradycardia, and irregular/slow respirations.
11. A patient on a mechanical ventilator has a high-pressure alarm sounding.
What is a common cause for this alarm?
A. Disconnection of the tubing
B. A leak in the ET tube cuff
C. Extubation
D. Patient biting the ET tube
Answer: D
