NUR2392/NUR 2392 Exam 3 V3 |
Multidimensional Care II (MDC 2) Q&A
with Rationale | Rasmussen University
1. A nurse is caring for a client with Chronic Kidney Disease (CKD) who has a serum potassium
level of 6.8 mEq/L. Which medication should the nurse anticipate administering first to
stabilize cardiac rhythm?
A. Calcium Gluconate
B. Sodium Polystyrene Sulfonate (Kayexalate)
C. Regular Insulin and Dextrose
D. Furosemide (Lasix)
Correct Answer: A
Rationale: Calcium Gluconate is administered in emergency hyperkalemia to antagonize
the cardiotoxic effects of high potassium and stabilize the myocardial membrane. While
insulin and dextrose move potassium into the cells and Kayexalate removes it from the
body, they do not work as quickly to protect the heart. The nurse must prioritize cardiac
stability before addressing the actual potassium level in severe cases.
2. A client diagnosed with cirrhosis is exhibiting increased confusion and asterixis. Which lab
result would the nurse expect to be elevated?
A. Serum Albumin
,B. Serum Creatinine
C. Ammonia
D. Prothrombin Time (PT)
Correct Answer: C
Rationale: Hepatic encephalopathy is primarily caused by the accumulation of ammonia in
the blood because the failing liver cannot convert it to urea. Confusion and asterixis (liver
flap) are classic neurological manifestations of this toxic buildup. Effective management
often involves medications like Lactulose to promote ammonia excretion through the
gastrointestinal tract.
3. A patient with Acute Kidney Injury (AKI) is in the oliguric phase. What clinical manifestation
should the nurse prioritize for assessment?
A. Dehydration and thirst
B. Jugular venous distention and crackles
C. Weight loss of 2 lbs in 24 hours
D. Hypotension and tachycardia
Correct Answer: B
Rationale: During the oliguric phase of AKI, the kidneys fail to excrete fluid, leading to fluid
volume excess. The nurse must monitor for signs of systemic congestion such as JVD,
, peripheral edema, and pulmonary crackles. Prompt recognition of fluid overload is
essential to prevent complications such as heart failure or pulmonary edema.
4. Which dietary instruction is most appropriate for a client with Stage 4 Chronic Kidney
Disease?
A. Limit potassium intake by avoiding bananas and spinach
B. Increase intake of high-protein foods like red meat
C. Supplement the diet with phosphorus-rich dairy products
D. Maintain a high-sodium diet to prevent hypotension
Correct Answer: A
Rationale: In Stage 4 CKD, the kidneys’ ability to filter electrolytes is significantly impaired,
necessitating strict dietary management. Potassium restriction is vital to prevent life-
threatening arrhythmias, while protein and phosphorus are usually limited to reduce the
renal workload. Patient education must focus on identifying ‘hidden’ sources of potassium
and phosphorus in processed foods.
5. A client is scheduled for a liver biopsy. In which position should the nurse place the client
immediately following the procedure?
A. High-Fowler’s position
B. Right-side-lying position
C. Left-side-lying position with a pillow
Multidimensional Care II (MDC 2) Q&A
with Rationale | Rasmussen University
1. A nurse is caring for a client with Chronic Kidney Disease (CKD) who has a serum potassium
level of 6.8 mEq/L. Which medication should the nurse anticipate administering first to
stabilize cardiac rhythm?
A. Calcium Gluconate
B. Sodium Polystyrene Sulfonate (Kayexalate)
C. Regular Insulin and Dextrose
D. Furosemide (Lasix)
Correct Answer: A
Rationale: Calcium Gluconate is administered in emergency hyperkalemia to antagonize
the cardiotoxic effects of high potassium and stabilize the myocardial membrane. While
insulin and dextrose move potassium into the cells and Kayexalate removes it from the
body, they do not work as quickly to protect the heart. The nurse must prioritize cardiac
stability before addressing the actual potassium level in severe cases.
2. A client diagnosed with cirrhosis is exhibiting increased confusion and asterixis. Which lab
result would the nurse expect to be elevated?
A. Serum Albumin
,B. Serum Creatinine
C. Ammonia
D. Prothrombin Time (PT)
Correct Answer: C
Rationale: Hepatic encephalopathy is primarily caused by the accumulation of ammonia in
the blood because the failing liver cannot convert it to urea. Confusion and asterixis (liver
flap) are classic neurological manifestations of this toxic buildup. Effective management
often involves medications like Lactulose to promote ammonia excretion through the
gastrointestinal tract.
3. A patient with Acute Kidney Injury (AKI) is in the oliguric phase. What clinical manifestation
should the nurse prioritize for assessment?
A. Dehydration and thirst
B. Jugular venous distention and crackles
C. Weight loss of 2 lbs in 24 hours
D. Hypotension and tachycardia
Correct Answer: B
Rationale: During the oliguric phase of AKI, the kidneys fail to excrete fluid, leading to fluid
volume excess. The nurse must monitor for signs of systemic congestion such as JVD,
, peripheral edema, and pulmonary crackles. Prompt recognition of fluid overload is
essential to prevent complications such as heart failure or pulmonary edema.
4. Which dietary instruction is most appropriate for a client with Stage 4 Chronic Kidney
Disease?
A. Limit potassium intake by avoiding bananas and spinach
B. Increase intake of high-protein foods like red meat
C. Supplement the diet with phosphorus-rich dairy products
D. Maintain a high-sodium diet to prevent hypotension
Correct Answer: A
Rationale: In Stage 4 CKD, the kidneys’ ability to filter electrolytes is significantly impaired,
necessitating strict dietary management. Potassium restriction is vital to prevent life-
threatening arrhythmias, while protein and phosphorus are usually limited to reduce the
renal workload. Patient education must focus on identifying ‘hidden’ sources of potassium
and phosphorus in processed foods.
5. A client is scheduled for a liver biopsy. In which position should the nurse place the client
immediately following the procedure?
A. High-Fowler’s position
B. Right-side-lying position
C. Left-side-lying position with a pillow
