NUR2392/NUR 2392 Final Exam V2 |
Multidimensional Care II (MDC 2) Q&A
with Rationale | Rasmussen University
1. A nurse is assessing a client with a potassium level of 2.8 mEq/L. Which of the following
clinical manifestations should the nurse identify as the priority?
A. Shallow respirations and respiratory distress
B. Abdominal distention and decreased bowel sounds
C. Orthostatic hypotension and weak pulse
D. Muscle weakness and diminished deep tendon reflexes
Correct Answer: A
Rationale: Hypokalemia significantly affects muscle contractility, including the diaphragm
and intercostal muscles used for breathing. Shallow respirations can lead to respiratory
arrest, making this the highest priority assessment based on the ABC (Airway, Breathing,
Circulation) framework. While muscle weakness and ileus are common, they are not
immediately life-threatening compared to respiratory failure.
2. A client presents to the emergency department with ABG results: pH 7.28, PaCO2 50
mmHg, and HCO3 24 mEq/L. How should the nurse interpret these findings?
A. Metabolic acidosis
B. Respiratory acidosis
,C. Respiratory alkalosis
D. Metabolic alkalosis
Correct Answer: B
Rationale: The pH of 7.28 indicates acidosis (less than 7.35). The PaCO2 is elevated at 50
mmHg, which is the primary cause of the acidic pH in respiratory systems. Since the HCO3
is within the normal range, the condition is uncompensated respiratory acidosis.
3. Which clinical manifestation is most characteristic of right-sided heart failure?
A. Crackles in the lung bases
B. Frothy, pink-tinged sputum
C. Paroxysmal nocturnal dyspnea
D. Jugular venous distention (JVD)
Correct Answer: D
Rationale: Right-sided heart failure results in systemic venous congestion because the
right ventricle cannot pump blood effectively into the pulmonary circuit. This leads to
increased pressure in the superior vena cava, manifesting as JVD and peripheral edema.
Symptoms like crackles and pink sputum are associated with left-sided failure and
pulmonary congestion.
, 4. A nurse is teaching a client with COPD about pursed-lip breathing. What is the primary
purpose of this technique?
A. To increase the rate of respirations
B. To reduce the amount of oxygen needed
C. To strengthen the intercostal muscles
D. To promote carbon dioxide elimination and keep airways open
Correct Answer: D
Rationale: Pursed-lip breathing creates mild resistance, which increases pressure in the
airways during exhalation. This prevents the smaller airways from collapsing, allowing for
more effective CO2 removal. It helps the client manage dyspnea and reduces the ‘air
trapping’ common in emphysema.
5. A client is admitted with Diabetic Ketoacidosis (DKA). Which of the following is an expected
physiological finding?
A. Kussmaul respirations
B. Bradypnea and hypoventilation
C. Respiratory alkalosis
D. High serum bicarbonate levels
Correct Answer: A
Multidimensional Care II (MDC 2) Q&A
with Rationale | Rasmussen University
1. A nurse is assessing a client with a potassium level of 2.8 mEq/L. Which of the following
clinical manifestations should the nurse identify as the priority?
A. Shallow respirations and respiratory distress
B. Abdominal distention and decreased bowel sounds
C. Orthostatic hypotension and weak pulse
D. Muscle weakness and diminished deep tendon reflexes
Correct Answer: A
Rationale: Hypokalemia significantly affects muscle contractility, including the diaphragm
and intercostal muscles used for breathing. Shallow respirations can lead to respiratory
arrest, making this the highest priority assessment based on the ABC (Airway, Breathing,
Circulation) framework. While muscle weakness and ileus are common, they are not
immediately life-threatening compared to respiratory failure.
2. A client presents to the emergency department with ABG results: pH 7.28, PaCO2 50
mmHg, and HCO3 24 mEq/L. How should the nurse interpret these findings?
A. Metabolic acidosis
B. Respiratory acidosis
,C. Respiratory alkalosis
D. Metabolic alkalosis
Correct Answer: B
Rationale: The pH of 7.28 indicates acidosis (less than 7.35). The PaCO2 is elevated at 50
mmHg, which is the primary cause of the acidic pH in respiratory systems. Since the HCO3
is within the normal range, the condition is uncompensated respiratory acidosis.
3. Which clinical manifestation is most characteristic of right-sided heart failure?
A. Crackles in the lung bases
B. Frothy, pink-tinged sputum
C. Paroxysmal nocturnal dyspnea
D. Jugular venous distention (JVD)
Correct Answer: D
Rationale: Right-sided heart failure results in systemic venous congestion because the
right ventricle cannot pump blood effectively into the pulmonary circuit. This leads to
increased pressure in the superior vena cava, manifesting as JVD and peripheral edema.
Symptoms like crackles and pink sputum are associated with left-sided failure and
pulmonary congestion.
, 4. A nurse is teaching a client with COPD about pursed-lip breathing. What is the primary
purpose of this technique?
A. To increase the rate of respirations
B. To reduce the amount of oxygen needed
C. To strengthen the intercostal muscles
D. To promote carbon dioxide elimination and keep airways open
Correct Answer: D
Rationale: Pursed-lip breathing creates mild resistance, which increases pressure in the
airways during exhalation. This prevents the smaller airways from collapsing, allowing for
more effective CO2 removal. It helps the client manage dyspnea and reduces the ‘air
trapping’ common in emphysema.
5. A client is admitted with Diabetic Ketoacidosis (DKA). Which of the following is an expected
physiological finding?
A. Kussmaul respirations
B. Bradypnea and hypoventilation
C. Respiratory alkalosis
D. High serum bicarbonate levels
Correct Answer: A
