NUR2392/NUR 2392 Final Exam V1 |
Multidimensional Care II (MDC 2) Q&A
with Rationale | Rasmussen University
1. A nurse is caring for a client who is 4 hours postoperative following an abdominal
hysterectomy. Which assessment finding should the nurse report to the provider
immediately?
A. Serosanguineous drainage on the abdominal dressing
B. Decreased bowel sounds in all four quadrants
C. Client report of pain at a level of 6 on a 0-to-10 scale
D. Urinary output of 20 mL/hr for the last 2 hours
Correct Answer: D
Rationale: A urinary output of less than 30 mL/hr is a significant indicator of potential
renal failure or hypovolemic shock in the postoperative period. The nurse must prioritize
this finding to ensure the client receives adequate fluid resuscitation or further diagnostic
evaluation. While decreased bowel sounds and pain are common after abdominal surgery,
low urine output requires immediate intervention to prevent complications.
2. A client is admitted with a potassium level of 6.5 mEq/L. Which of the following
electrocardiogram (ECG) changes should the nurse expect to observe?
A. Prominent U waves
,B. ST-segment depression
C. Tall, peaked T waves
D. Shortened PR interval
Correct Answer: C
Rationale: Hyperkalemia is characterized by specific ECG changes, most notably the
presence of tall, peaked T waves due to rapid repolarization of the myocardium. This
condition is a medical emergency as it can progress to ventricular fibrillation or cardiac
arrest if not treated promptly. The nurse should continue to monitor the cardiac rhythm
and prepare for interventions such as sodium polystyrene sulfonate or insulin/dextrose
administration.
3. A nurse is teaching a client about the use of an incentive spirometer. Which instruction
should the nurse include in the teaching?
A. Exhale as hard as possible into the device
B. Hold your breath for 15 seconds after inhalation
C. Use the device only if you feel short of breath
D. Inhale slowly and deeply through the mouthpiece
Correct Answer: D
Rationale: The primary goal of using an incentive spirometer is to promote lung expansion
and prevent atelectasis by encouraging deep breathing. The client should be instructed to
, inhale slowly and deeply to keep the indicator at the target level for several seconds. This
practice helps to re-inflate the alveoli and is essential for postoperative recovery to prevent
pneumonia.
4. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 L/min
via nasal cannula. The nurse notes the client’s oxygen saturation is 89%. What is the most
appropriate action by the nurse?
A. Document the finding as normal for this client
B. Increase the oxygen flow rate to 6 L/min
C. Immediately switch to a non-rebreather mask
D. Notify the rapid response team
Correct Answer: A
Rationale: In clients with COPD, a target oxygen saturation between 88% and 92% is often
acceptable because high levels of oxygen can suppress their drive to breathe. The nurse
must understand that for these individuals, the hypoxic drive is what stimulates
respiration. Therefore, an 89% saturation level is a stable and expected finding for many
COPD patients on low-flow oxygen.
5. A nurse is assessing a client with right-sided heart failure. Which clinical manifestation
should the nurse expect to find?
A. Jugular venous distention (JVD)
B. Crackles in the lungs
Multidimensional Care II (MDC 2) Q&A
with Rationale | Rasmussen University
1. A nurse is caring for a client who is 4 hours postoperative following an abdominal
hysterectomy. Which assessment finding should the nurse report to the provider
immediately?
A. Serosanguineous drainage on the abdominal dressing
B. Decreased bowel sounds in all four quadrants
C. Client report of pain at a level of 6 on a 0-to-10 scale
D. Urinary output of 20 mL/hr for the last 2 hours
Correct Answer: D
Rationale: A urinary output of less than 30 mL/hr is a significant indicator of potential
renal failure or hypovolemic shock in the postoperative period. The nurse must prioritize
this finding to ensure the client receives adequate fluid resuscitation or further diagnostic
evaluation. While decreased bowel sounds and pain are common after abdominal surgery,
low urine output requires immediate intervention to prevent complications.
2. A client is admitted with a potassium level of 6.5 mEq/L. Which of the following
electrocardiogram (ECG) changes should the nurse expect to observe?
A. Prominent U waves
,B. ST-segment depression
C. Tall, peaked T waves
D. Shortened PR interval
Correct Answer: C
Rationale: Hyperkalemia is characterized by specific ECG changes, most notably the
presence of tall, peaked T waves due to rapid repolarization of the myocardium. This
condition is a medical emergency as it can progress to ventricular fibrillation or cardiac
arrest if not treated promptly. The nurse should continue to monitor the cardiac rhythm
and prepare for interventions such as sodium polystyrene sulfonate or insulin/dextrose
administration.
3. A nurse is teaching a client about the use of an incentive spirometer. Which instruction
should the nurse include in the teaching?
A. Exhale as hard as possible into the device
B. Hold your breath for 15 seconds after inhalation
C. Use the device only if you feel short of breath
D. Inhale slowly and deeply through the mouthpiece
Correct Answer: D
Rationale: The primary goal of using an incentive spirometer is to promote lung expansion
and prevent atelectasis by encouraging deep breathing. The client should be instructed to
, inhale slowly and deeply to keep the indicator at the target level for several seconds. This
practice helps to re-inflate the alveoli and is essential for postoperative recovery to prevent
pneumonia.
4. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 L/min
via nasal cannula. The nurse notes the client’s oxygen saturation is 89%. What is the most
appropriate action by the nurse?
A. Document the finding as normal for this client
B. Increase the oxygen flow rate to 6 L/min
C. Immediately switch to a non-rebreather mask
D. Notify the rapid response team
Correct Answer: A
Rationale: In clients with COPD, a target oxygen saturation between 88% and 92% is often
acceptable because high levels of oxygen can suppress their drive to breathe. The nurse
must understand that for these individuals, the hypoxic drive is what stimulates
respiration. Therefore, an 89% saturation level is a stable and expected finding for many
COPD patients on low-flow oxygen.
5. A nurse is assessing a client with right-sided heart failure. Which clinical manifestation
should the nurse expect to find?
A. Jugular venous distention (JVD)
B. Crackles in the lungs
