NUR2392/NUR 2392 Final Exam V3 |
Multidimensional Care II (MDC 2) Q&A
with Rationale | Rasmussen University
1. A nurse is caring for a client with a serum potassium level of 6.2 mEq/L. Which EKG finding
should the nurse prioritize for reporting?
A. Prominent U waves
B. Inverted P waves
C. ST-segment depression
D. Tall, peaked T waves
Correct Answer: D
Rationale: Hyperkalemia is defined as a serum potassium level greater than 5.0 mEq/L
and can lead to life-threatening cardiac arrhythmias. Tall, peaked T waves are a classic
early sign of hyperkalemia on an electrocardiogram. The nurse must recognize this finding
immediately to initiate treatment such as calcium gluconate or insulin with dextrose to
prevent cardiac arrest.
2. A client with chronic obstructive pulmonary disease (COPD) is being discharged. Which
statement by the client indicates a need for further teaching regarding oxygen therapy?
A. I will keep my oxygen tubing away from open flames.
B. I should increase my oxygen flow rate if I feel more short of breath.
,C. I will use water-based lubricants on my lips instead of petroleum jelly.
D. I need to check my skin behind my ears for redness from the tubing.
Correct Answer: B
Rationale: In clients with COPD, the drive to breathe is often triggered by low oxygen
levels rather than high carbon dioxide levels. Increasing oxygen flow rates without a
prescription can suppress this hypoxic drive and lead to respiratory depression or carbon
dioxide narcosis. The nurse must emphasize that the oxygen flow rate is a medication
dosage and should not be adjusted by the client.
3. The nurse is assessing a client for signs of left-sided heart failure. Which clinical
manifestation should the nurse expect to find?
A. Jugular venous distention
B. Crackles in the lung bases
C. Dependent peripheral edema
D. Hepatomegaly and ascites
Correct Answer: B
Rationale: Left-sided heart failure primarily affects the pulmonary system because the left
ventricle cannot effectively pump blood into systemic circulation. This results in backflow
of blood into the pulmonary veins and capillaries, leading to pulmonary congestion and
crackles upon auscultation. Symptoms like jugular venous distention and peripheral edema
are more characteristic of right-sided heart failure.
, 4. A client is diagnosed with hypocalcemia. Which physical assessment technique should the
nurse perform to check for neuromuscular irritability?
A. Check for a positive Babinski sign.
B. Assess for a positive Chvostek’s sign.
C. Perform a Romberg test.
D. Elicit a Brudzinski sign.
Correct Answer: B
Rationale: Chvostek’s sign is elicited by tapping the facial nerve in front of the ear; a
positive response is a twitching of the facial muscles. This finding indicates hypocalcemia-
induced neuromuscular irritability and increased excitability of nerves. Trousseau’s sign is
another clinical indicator of hypocalcemia involving carpal spasm when a blood pressure
cuff is inflated.
5. A client is prescribed Digoxin for heart failure. Which electrolyte imbalance should the
nurse monitor most closely to prevent Digoxin toxicity?
A. Hypernatremia
B. Hypomagnesemia
C. Hypercalcemia
D. Hypokalemia
Correct Answer: D
Multidimensional Care II (MDC 2) Q&A
with Rationale | Rasmussen University
1. A nurse is caring for a client with a serum potassium level of 6.2 mEq/L. Which EKG finding
should the nurse prioritize for reporting?
A. Prominent U waves
B. Inverted P waves
C. ST-segment depression
D. Tall, peaked T waves
Correct Answer: D
Rationale: Hyperkalemia is defined as a serum potassium level greater than 5.0 mEq/L
and can lead to life-threatening cardiac arrhythmias. Tall, peaked T waves are a classic
early sign of hyperkalemia on an electrocardiogram. The nurse must recognize this finding
immediately to initiate treatment such as calcium gluconate or insulin with dextrose to
prevent cardiac arrest.
2. A client with chronic obstructive pulmonary disease (COPD) is being discharged. Which
statement by the client indicates a need for further teaching regarding oxygen therapy?
A. I will keep my oxygen tubing away from open flames.
B. I should increase my oxygen flow rate if I feel more short of breath.
,C. I will use water-based lubricants on my lips instead of petroleum jelly.
D. I need to check my skin behind my ears for redness from the tubing.
Correct Answer: B
Rationale: In clients with COPD, the drive to breathe is often triggered by low oxygen
levels rather than high carbon dioxide levels. Increasing oxygen flow rates without a
prescription can suppress this hypoxic drive and lead to respiratory depression or carbon
dioxide narcosis. The nurse must emphasize that the oxygen flow rate is a medication
dosage and should not be adjusted by the client.
3. The nurse is assessing a client for signs of left-sided heart failure. Which clinical
manifestation should the nurse expect to find?
A. Jugular venous distention
B. Crackles in the lung bases
C. Dependent peripheral edema
D. Hepatomegaly and ascites
Correct Answer: B
Rationale: Left-sided heart failure primarily affects the pulmonary system because the left
ventricle cannot effectively pump blood into systemic circulation. This results in backflow
of blood into the pulmonary veins and capillaries, leading to pulmonary congestion and
crackles upon auscultation. Symptoms like jugular venous distention and peripheral edema
are more characteristic of right-sided heart failure.
, 4. A client is diagnosed with hypocalcemia. Which physical assessment technique should the
nurse perform to check for neuromuscular irritability?
A. Check for a positive Babinski sign.
B. Assess for a positive Chvostek’s sign.
C. Perform a Romberg test.
D. Elicit a Brudzinski sign.
Correct Answer: B
Rationale: Chvostek’s sign is elicited by tapping the facial nerve in front of the ear; a
positive response is a twitching of the facial muscles. This finding indicates hypocalcemia-
induced neuromuscular irritability and increased excitability of nerves. Trousseau’s sign is
another clinical indicator of hypocalcemia involving carpal spasm when a blood pressure
cuff is inflated.
5. A client is prescribed Digoxin for heart failure. Which electrolyte imbalance should the
nurse monitor most closely to prevent Digoxin toxicity?
A. Hypernatremia
B. Hypomagnesemia
C. Hypercalcemia
D. Hypokalemia
Correct Answer: D
