NUR2392/NUR 2392 Exam 1 V2 |
Multidimensional Care II (MDC 2) Q&A
with Rationale | Rasmussen University
1. A nurse is preparing a client for an elective surgery. The client expresses concern because
they do not fully understand the risks of the procedure. What is the priority nursing action?
A. Explain the risks and benefits of the surgery to the client.
B. Ask the client to sign the consent form and document the concerns.
C. Notify the surgeon that the client requires further clarification.
D. Provide the client with an educational pamphlet about the surgery.
Correct Answer: C
Rationale: The surgeon is legally responsible for providing a detailed explanation of the
procedure, including risks and benefits. The nurse’s role in informed consent is to witness
the signature and ensure the client is competent. If the client lacks understanding, the
nurse must advocate for the client by requesting the surgeon return for further discussion.
2. A client is 4 hours postoperative following abdominal surgery. The nurse notes the client’s
heart rate is 115 bpm and blood pressure is 92/58 mmHg. Which action should the nurse take
first?
A. Administer the prescribed PRN pain medication.
B. Increase the rate of the intravenous fluids.
,C. Encourage the client to use the incentive spirometer.
D. Notify the rapid response team or the surgeon immediately.
Correct Answer: D
Rationale: Tachycardia and hypotension in the immediate postoperative period are classic
signs of hypovolemic shock or internal hemorrhage. This is a medical emergency that
requires immediate provider intervention to prevent further deterioration. The nurse
should stabilize the client while awaiting the surgical team’s orders.
3. The nurse is reviewing laboratory results for a client with heart failure. The potassium level
is 5.8 mEq/L. Which assessment finding is the priority?
A. Hyperactive bowel sounds and diarrhea.
B. Increased urinary output.
C. Muscle weakness in the lower extremities.
D. Cardiac dysrhythmias and ECG changes.
Correct Answer: D
Rationale: Hyperkalemia is life-threatening because it directly affects the electrical
conduction of the heart. Levels above 5.0 mEq/L can cause peaked T waves, widened QRS
complexes, and potentially cardiac arrest. Monitoring the ECG and assessing for
dysrhythmias is the highest priority for client safety.
, 4. A nurse is caring for a client with a nasogastric (NG) tube set to continuous low suction. For
which acid-base imbalance is this client at greatest risk?
A. Metabolic Alkalosis
B. Metabolic Acidosis
C. Respiratory Alkalosis
D. Respiratory Acidosis
Correct Answer: A
Rationale: Gastric secretions are highly acidic; when they are removed via suction, the
body loses hydrogen ions. This loss of acid leads to an increase in the pH and bicarbonate
levels in the blood. Metabolic alkalosis is the result of this excessive loss of gastric acid.
5. A client receiving chemotherapy has a platelet count of 45,000/mm3. Which intervention
should the nurse include in the plan of care?
A. Administer aspirin for any complaints of headache.
B. Encourage the use of an electric razor for shaving.
C. Perform vigorous oral hygiene with a firm toothbrush.
D. Apply a warm compress to any bruised areas.
Correct Answer: B
Rationale: Thrombocytopenia, defined as a low platelet count, significantly increases the
risk for spontaneous or prolonged bleeding. Using an electric razor prevents skin nicks that
Multidimensional Care II (MDC 2) Q&A
with Rationale | Rasmussen University
1. A nurse is preparing a client for an elective surgery. The client expresses concern because
they do not fully understand the risks of the procedure. What is the priority nursing action?
A. Explain the risks and benefits of the surgery to the client.
B. Ask the client to sign the consent form and document the concerns.
C. Notify the surgeon that the client requires further clarification.
D. Provide the client with an educational pamphlet about the surgery.
Correct Answer: C
Rationale: The surgeon is legally responsible for providing a detailed explanation of the
procedure, including risks and benefits. The nurse’s role in informed consent is to witness
the signature and ensure the client is competent. If the client lacks understanding, the
nurse must advocate for the client by requesting the surgeon return for further discussion.
2. A client is 4 hours postoperative following abdominal surgery. The nurse notes the client’s
heart rate is 115 bpm and blood pressure is 92/58 mmHg. Which action should the nurse take
first?
A. Administer the prescribed PRN pain medication.
B. Increase the rate of the intravenous fluids.
,C. Encourage the client to use the incentive spirometer.
D. Notify the rapid response team or the surgeon immediately.
Correct Answer: D
Rationale: Tachycardia and hypotension in the immediate postoperative period are classic
signs of hypovolemic shock or internal hemorrhage. This is a medical emergency that
requires immediate provider intervention to prevent further deterioration. The nurse
should stabilize the client while awaiting the surgical team’s orders.
3. The nurse is reviewing laboratory results for a client with heart failure. The potassium level
is 5.8 mEq/L. Which assessment finding is the priority?
A. Hyperactive bowel sounds and diarrhea.
B. Increased urinary output.
C. Muscle weakness in the lower extremities.
D. Cardiac dysrhythmias and ECG changes.
Correct Answer: D
Rationale: Hyperkalemia is life-threatening because it directly affects the electrical
conduction of the heart. Levels above 5.0 mEq/L can cause peaked T waves, widened QRS
complexes, and potentially cardiac arrest. Monitoring the ECG and assessing for
dysrhythmias is the highest priority for client safety.
, 4. A nurse is caring for a client with a nasogastric (NG) tube set to continuous low suction. For
which acid-base imbalance is this client at greatest risk?
A. Metabolic Alkalosis
B. Metabolic Acidosis
C. Respiratory Alkalosis
D. Respiratory Acidosis
Correct Answer: A
Rationale: Gastric secretions are highly acidic; when they are removed via suction, the
body loses hydrogen ions. This loss of acid leads to an increase in the pH and bicarbonate
levels in the blood. Metabolic alkalosis is the result of this excessive loss of gastric acid.
5. A client receiving chemotherapy has a platelet count of 45,000/mm3. Which intervention
should the nurse include in the plan of care?
A. Administer aspirin for any complaints of headache.
B. Encourage the use of an electric razor for shaving.
C. Perform vigorous oral hygiene with a firm toothbrush.
D. Apply a warm compress to any bruised areas.
Correct Answer: B
Rationale: Thrombocytopenia, defined as a low platelet count, significantly increases the
risk for spontaneous or prolonged bleeding. Using an electric razor prevents skin nicks that
