NUR2392/NUR 2392 Exam 4 V3 |
Multidimensional Care II (MDC 2) Q&A
with Rationale | Rasmussen University
1. A client is admitted with acute respiratory distress syndrome (ARDS). Which ventilator
setting should the nurse anticipate to improve oxygenation by keeping the alveoli open at the
end of expiration?
A. Positive end-expiratory pressure (PEEP)
B. Fraction of inspired oxygen (FiO2) at 100%
C. Tidal volume at 15 mL/kg
D. Inspiratory-to-expiratory (I:E) ratio of 1:2
Correct Answer: A
Rationale: Positive end-expiratory pressure (PEEP) is used in ARDS to prevent alveolar
collapse and improve gas exchange. It works by maintaining a set pressure in the lungs at
the end of the respiratory cycle, which increases the functional residual capacity. This
intervention is critical for treating refractory hypoxemia commonly seen in
multidimensional care of respiratory failure.
2. The nurse is caring for a client with a permanent pacemaker. Which finding on the cardiac
monitor indicates a failure to sense?
A. Pacemaker spikes appear but are not followed by a QRS complex.
,B. The client’s heart rate is 45 beats per minute with no pacemaker activity.
C. Pacemaker spikes are present on top of the client’s own T-waves.
D. The monitor shows a flat line with intermittent P-waves.
Correct Answer: C
Rationale: Failure to sense occurs when the pacemaker does not recognize the heart’s
intrinsic electrical activity and fires at inappropriate times. This is evidenced by pacemaker
spikes falling randomly in the cardiac cycle, such as on the T-wave, which poses a risk for
R-on-T phenomenon. The nurse must recognize this as a potential emergency requiring
sensitivity adjustment to ensure client safety.
3. A client with chronic kidney disease (CKD) has a serum potassium level of 6.8 mEq/L. Which
medication should the nurse be prepared to administer first to protect the heart from
dysrhythmias?
A. Sodium polystyrene sulfonate
B. Furosemide
C. Regular insulin and Dextrose 50%
D. Calcium gluconate
Correct Answer: D
Rationale: Calcium gluconate is administered in severe hyperkalemia to stabilize the
myocardial cell membrane and prevent lethal dysrhythmias. While insulin and sodium
, polystyrene sulfonate help lower potassium levels, they do not provide immediate cardiac
protection. Protecting the heart is the clinical priority in the acute phase of electrolyte
imbalance management.
4. Which assessment finding should the nurse prioritize for a client who underwent a
percutaneous coronary intervention (PCI) via the femoral artery two hours ago?
A. Diminished pedal pulses in the affected extremity.
B. Report of back pain or flank pain.
C. A small bruise at the insertion site.
D. Blood pressure of 110/70 mmHg.
Correct Answer: B
Rationale: Back or flank pain after a femoral PCI can indicate a retroperitoneal bleed,
which is a life-threatening complication. The nurse must monitor for signs of internal
hemorrhage such as hypotension and tachycardia in conjunction with this pain. Immediate
notification of the healthcare provider is necessary to prevent hypovolemic shock.
5. A client is in the oliguric phase of acute kidney injury (AKI). Which electrolyte abnormality
is the nurse most likely to observe?
A. Hypermagnesemia
B. Hypercalcemia
C. Hypokalemia
Multidimensional Care II (MDC 2) Q&A
with Rationale | Rasmussen University
1. A client is admitted with acute respiratory distress syndrome (ARDS). Which ventilator
setting should the nurse anticipate to improve oxygenation by keeping the alveoli open at the
end of expiration?
A. Positive end-expiratory pressure (PEEP)
B. Fraction of inspired oxygen (FiO2) at 100%
C. Tidal volume at 15 mL/kg
D. Inspiratory-to-expiratory (I:E) ratio of 1:2
Correct Answer: A
Rationale: Positive end-expiratory pressure (PEEP) is used in ARDS to prevent alveolar
collapse and improve gas exchange. It works by maintaining a set pressure in the lungs at
the end of the respiratory cycle, which increases the functional residual capacity. This
intervention is critical for treating refractory hypoxemia commonly seen in
multidimensional care of respiratory failure.
2. The nurse is caring for a client with a permanent pacemaker. Which finding on the cardiac
monitor indicates a failure to sense?
A. Pacemaker spikes appear but are not followed by a QRS complex.
,B. The client’s heart rate is 45 beats per minute with no pacemaker activity.
C. Pacemaker spikes are present on top of the client’s own T-waves.
D. The monitor shows a flat line with intermittent P-waves.
Correct Answer: C
Rationale: Failure to sense occurs when the pacemaker does not recognize the heart’s
intrinsic electrical activity and fires at inappropriate times. This is evidenced by pacemaker
spikes falling randomly in the cardiac cycle, such as on the T-wave, which poses a risk for
R-on-T phenomenon. The nurse must recognize this as a potential emergency requiring
sensitivity adjustment to ensure client safety.
3. A client with chronic kidney disease (CKD) has a serum potassium level of 6.8 mEq/L. Which
medication should the nurse be prepared to administer first to protect the heart from
dysrhythmias?
A. Sodium polystyrene sulfonate
B. Furosemide
C. Regular insulin and Dextrose 50%
D. Calcium gluconate
Correct Answer: D
Rationale: Calcium gluconate is administered in severe hyperkalemia to stabilize the
myocardial cell membrane and prevent lethal dysrhythmias. While insulin and sodium
, polystyrene sulfonate help lower potassium levels, they do not provide immediate cardiac
protection. Protecting the heart is the clinical priority in the acute phase of electrolyte
imbalance management.
4. Which assessment finding should the nurse prioritize for a client who underwent a
percutaneous coronary intervention (PCI) via the femoral artery two hours ago?
A. Diminished pedal pulses in the affected extremity.
B. Report of back pain or flank pain.
C. A small bruise at the insertion site.
D. Blood pressure of 110/70 mmHg.
Correct Answer: B
Rationale: Back or flank pain after a femoral PCI can indicate a retroperitoneal bleed,
which is a life-threatening complication. The nurse must monitor for signs of internal
hemorrhage such as hypotension and tachycardia in conjunction with this pain. Immediate
notification of the healthcare provider is necessary to prevent hypovolemic shock.
5. A client is in the oliguric phase of acute kidney injury (AKI). Which electrolyte abnormality
is the nurse most likely to observe?
A. Hypermagnesemia
B. Hypercalcemia
C. Hypokalemia
