NUR 2356 / NUR2356: Multidimensional Care I /
MDC 1 Exam 2 – Rasmussen Actual Exam
Complete Questions & Rationales | Foundational
Care | Pass Guaranteed - A+ Graded
Foundations of Multidimensional Care
Q1: What is the normal serum potassium level for an adult patient?
A. 3.1 mEq/L
B. 5.8 mEq/L
C. 3.9 mEq/L [CORRECT]
D. 6.2 mEq/L
Correct Answer: C
Rationale: The best answer is C because a normal potassium level falls right between
3.5 and 5.0 mEq/L, making 3.9 a perfectly normal value. We wouldn't want to see it at
3.1 because that's too low and causes weakness, and the other two are way too high,
which puts the patient at risk for serious heart rhythm issues.
Q2: When we talk about data clustering in nursing, what are we actually doing?
A. Grouping unrelated assessment findings to get a full picture of the patient
B. Organizing assessment data into meaningful patterns to identify specific patient
problems [CORRECT]
C. Separating subjective data from objective data for the physician to review
D. Documenting every single vital sign and lab result in chronological order
Correct Answer: B
Rationale: This is correct because data clustering is all about taking pieces of the
assessment and putting them together like a puzzle so you can see what's actually
going on with the patient. It’s not just about making lists or separating subjective from
objective data; it’s about finding the pattern that points to a nursing diagnosis.
Q3: Which of the following arterial blood gas (ABG) results indicates a normal pH?
A. 7.30
B. 7.48
C. 7.35
D. 7.40 [CORRECT]
Correct Answer: D
,Rationale: That matches the normal range because a pH of 7.40 is right in the middle of
the normal 7.35 to 7.45 window. The other options are either on the acidic side or the
alkaline side, which means the patient is already experiencing an imbalance.
Q4: You are assessing your patient's capillary refill and note that the color returns to the
fingertip in 2 seconds. How do you document this finding?
A. Capillary refill delayed at 2 seconds
B. Capillary refill brisk and within normal limits [CORRECT]
C. Capillary refill normal at 4 seconds
D. Capillary refill absent in lower extremities
Correct Answer: B
Rationale: In practice, we consider anything under 3 seconds to be a normal, brisk
capillary refill, so 2 seconds is exactly what we want to see. We wouldn't call it delayed,
and saying it takes 4 seconds would actually be incorrect because that points to poor
perfusion.
Q5: Your patient is 2 days post-op from an abdominal surgery and is refusing to take
deep breaths because it hurts too much. Which intervention should you try first to help
with their pain so they can cough and deep breathe?
A. Administer the prescribed PRN IV opioid
B. Provide a pillow to splint their incision before coughing [CORRECT]
C. Call the physical therapist for a walking order
D. Apply a warm heating pad to the abdomen
Correct Answer: B
Rationale: The best answer is B because splinting the abdomen is a simple, immediate
nursing intervention that reduces pain during movement without just jumping straight to
medication. While the IV opioid might be needed if the pain is severe, we always want
to try non-pharmacological comfort measures first to see if that gives the patient enough
relief to do what they need to do.
Q6: You are caring for a patient who has been on strict bed rest for three days. Which
nursing intervention is most important to include in their care plan to prevent
complications of immobility?
A. Encouraging high-protein shakes at every meal
B. Performing passive range of motion exercises to all extremities twice a day
[CORRECT]
C. Keeping the head of the bed flat at all times
D. Applying sequential compression devices only during the night shift
Correct Answer: B
Rationale: This is correct because when a patient is stuck in bed, their joints get stiff
and they lose muscle tone pretty quickly, so range of motion keeps things moving.
, Keeping the head of the bed flat all the time actually hurts their breathing, and
compression devices need to be on consistently when the patient is in bed, not just at
night.
Q7: You are getting ready to change a surgical dressing and notice the sterile saline
bottle was opened 24 hours ago on the previous shift. What should you do?
A. Go ahead and use it since it was just saline and the bottle is closed
B. Use it but pour a small amount out first to "clean" the rim
C. Discard the bottle and get a new unopened bottle of sterile saline [CORRECT]
D. Ask the charge nurse if it is okay to use it just this once
Correct Answer: C
Rationale: In practice, we would immediately throw that out and get a fresh bottle
because once sterile fluids are opened, they are only good for 24 hours and we can't
guarantee it's still sterile. Using it would completely break our sterile technique and put
the patient at risk for a surgical site infection, regardless of what the charge nurse says.
Q8: A patient has a stage 2 pressure injury on their sacrum. What is the most accurate
way to describe this type of wound during your handoff report?
A. A shallow, open ulcer with a red-pink wound bed without slough [CORRECT]
B. A deep crater extending into the subcutaneous fat and muscle
C. Full-thickness tissue loss with exposed bone
D. Intact skin with a localized area of non-blanchable redness
Correct Answer: A
Rationale: That matches the priority framework for staging pressure injuries because a
stage 2 is a partial-thickness skin loss that looks like a shallow open ulcer with a red or
pink bed. The deeper descriptions belong to stages 3 and 4, and intact non-blanchable
skin is how we describe a stage 1 injury.
Q9: Your patient has been diagnosed with fluid volume excess. Which assessment
finding would you expect to see when you go into their room?
A. Dry mucous membranes and flat neck veins
B. Bounding peripheral pulses and crackles in the lungs [CORRECT]
C. Increased urine output and severe thirst
D. Weakness and a sudden drop in blood pressure
Correct Answer: B
Rationale: This is correct because when a patient is holding onto too much fluid, that
extra fluid backs up into their vascular system causing bounding pulses, and it leaks into
their lungs causing those crackling sounds we hear. The other options describe a
patient who is dehydrated and lacking fluid, which is the exact opposite problem.
MDC 1 Exam 2 – Rasmussen Actual Exam
Complete Questions & Rationales | Foundational
Care | Pass Guaranteed - A+ Graded
Foundations of Multidimensional Care
Q1: What is the normal serum potassium level for an adult patient?
A. 3.1 mEq/L
B. 5.8 mEq/L
C. 3.9 mEq/L [CORRECT]
D. 6.2 mEq/L
Correct Answer: C
Rationale: The best answer is C because a normal potassium level falls right between
3.5 and 5.0 mEq/L, making 3.9 a perfectly normal value. We wouldn't want to see it at
3.1 because that's too low and causes weakness, and the other two are way too high,
which puts the patient at risk for serious heart rhythm issues.
Q2: When we talk about data clustering in nursing, what are we actually doing?
A. Grouping unrelated assessment findings to get a full picture of the patient
B. Organizing assessment data into meaningful patterns to identify specific patient
problems [CORRECT]
C. Separating subjective data from objective data for the physician to review
D. Documenting every single vital sign and lab result in chronological order
Correct Answer: B
Rationale: This is correct because data clustering is all about taking pieces of the
assessment and putting them together like a puzzle so you can see what's actually
going on with the patient. It’s not just about making lists or separating subjective from
objective data; it’s about finding the pattern that points to a nursing diagnosis.
Q3: Which of the following arterial blood gas (ABG) results indicates a normal pH?
A. 7.30
B. 7.48
C. 7.35
D. 7.40 [CORRECT]
Correct Answer: D
,Rationale: That matches the normal range because a pH of 7.40 is right in the middle of
the normal 7.35 to 7.45 window. The other options are either on the acidic side or the
alkaline side, which means the patient is already experiencing an imbalance.
Q4: You are assessing your patient's capillary refill and note that the color returns to the
fingertip in 2 seconds. How do you document this finding?
A. Capillary refill delayed at 2 seconds
B. Capillary refill brisk and within normal limits [CORRECT]
C. Capillary refill normal at 4 seconds
D. Capillary refill absent in lower extremities
Correct Answer: B
Rationale: In practice, we consider anything under 3 seconds to be a normal, brisk
capillary refill, so 2 seconds is exactly what we want to see. We wouldn't call it delayed,
and saying it takes 4 seconds would actually be incorrect because that points to poor
perfusion.
Q5: Your patient is 2 days post-op from an abdominal surgery and is refusing to take
deep breaths because it hurts too much. Which intervention should you try first to help
with their pain so they can cough and deep breathe?
A. Administer the prescribed PRN IV opioid
B. Provide a pillow to splint their incision before coughing [CORRECT]
C. Call the physical therapist for a walking order
D. Apply a warm heating pad to the abdomen
Correct Answer: B
Rationale: The best answer is B because splinting the abdomen is a simple, immediate
nursing intervention that reduces pain during movement without just jumping straight to
medication. While the IV opioid might be needed if the pain is severe, we always want
to try non-pharmacological comfort measures first to see if that gives the patient enough
relief to do what they need to do.
Q6: You are caring for a patient who has been on strict bed rest for three days. Which
nursing intervention is most important to include in their care plan to prevent
complications of immobility?
A. Encouraging high-protein shakes at every meal
B. Performing passive range of motion exercises to all extremities twice a day
[CORRECT]
C. Keeping the head of the bed flat at all times
D. Applying sequential compression devices only during the night shift
Correct Answer: B
Rationale: This is correct because when a patient is stuck in bed, their joints get stiff
and they lose muscle tone pretty quickly, so range of motion keeps things moving.
, Keeping the head of the bed flat all the time actually hurts their breathing, and
compression devices need to be on consistently when the patient is in bed, not just at
night.
Q7: You are getting ready to change a surgical dressing and notice the sterile saline
bottle was opened 24 hours ago on the previous shift. What should you do?
A. Go ahead and use it since it was just saline and the bottle is closed
B. Use it but pour a small amount out first to "clean" the rim
C. Discard the bottle and get a new unopened bottle of sterile saline [CORRECT]
D. Ask the charge nurse if it is okay to use it just this once
Correct Answer: C
Rationale: In practice, we would immediately throw that out and get a fresh bottle
because once sterile fluids are opened, they are only good for 24 hours and we can't
guarantee it's still sterile. Using it would completely break our sterile technique and put
the patient at risk for a surgical site infection, regardless of what the charge nurse says.
Q8: A patient has a stage 2 pressure injury on their sacrum. What is the most accurate
way to describe this type of wound during your handoff report?
A. A shallow, open ulcer with a red-pink wound bed without slough [CORRECT]
B. A deep crater extending into the subcutaneous fat and muscle
C. Full-thickness tissue loss with exposed bone
D. Intact skin with a localized area of non-blanchable redness
Correct Answer: A
Rationale: That matches the priority framework for staging pressure injuries because a
stage 2 is a partial-thickness skin loss that looks like a shallow open ulcer with a red or
pink bed. The deeper descriptions belong to stages 3 and 4, and intact non-blanchable
skin is how we describe a stage 1 injury.
Q9: Your patient has been diagnosed with fluid volume excess. Which assessment
finding would you expect to see when you go into their room?
A. Dry mucous membranes and flat neck veins
B. Bounding peripheral pulses and crackles in the lungs [CORRECT]
C. Increased urine output and severe thirst
D. Weakness and a sudden drop in blood pressure
Correct Answer: B
Rationale: This is correct because when a patient is holding onto too much fluid, that
extra fluid backs up into their vascular system causing bounding pulses, and it leaks into
their lungs causing those crackling sounds we hear. The other options describe a
patient who is dehydrated and lacking fluid, which is the exact opposite problem.
