NUR 2502 NUR2502 MULTIDIMENSIONAL
CARE III FINAL EXAM QUESTIONS AND
CORRECT DETAILED ANSWERS PLUS
RATIONALES 2025 RASMUSSEN UNIVERSITY
1. A nurse is caring for a client with a C6 spinal cord injury. Which finding
requires immediate intervention?
A. Flaccid paralysis of lower extremities
B. Warm, flushed skin and bradycardia
C. Blood pressure 80/50 mm Hg and heart rate 120 bpm
D. Loss of sensation below the level of injury
A low blood pressure and high heart rate indicate neurogenic shock,
which is life-threatening and requires immediate action.
2. Which lab value is most critical to monitor in a client receiving furosemide?
A. Hemoglobin
B. Sodium
C. Potassium
D. Creatinine
, Furosemide is a loop diuretic that can cause hypokalemia, increasing the
risk for cardiac dysrhythmias.
3. A nurse is reviewing medication orders for a client with increased
intracranial pressure. Which medication should the nurse question?
A. Morphine sulfate IV
B. Mannitol IV
C. Dexamethasone IV
D. Hypertonic saline IV
Morphine can cause respiratory depression and CO2 retention, leading to
vasodilation and increased ICP.
4. A client is in septic shock. Which finding indicates effective fluid
resuscitation?
A. Decreased urine output
B. Mean arterial pressure (MAP) >65 mm Hg
C. Increased lactate level
D. Cold, clammy skin
MAP above 65 mm Hg indicates adequate organ perfusion and effective
fluid resuscitation.
5. A nurse is assessing a client with a chest tube. Which finding should be
reported immediately?
A. Intermittent bubbling in the suction chamber
B. Continuous bubbling in the water-seal chamber
C. No drainage in the collection chamber for 2 hours
D. Drainage of 30 mL/hr
, Continuous bubbling in the water-seal chamber indicates an air leak and
must be reported.
6. Which assessment finding is expected in a client with left-sided heart
failure?
A. Jugular vein distention
B. Crackles in lungs
C. Peripheral edema
D. Ascites
Left-sided heart failure leads to pulmonary congestion, resulting in
crackles.
7. A client post-thyroidectomy reports tingling in the fingers. What is the
priority action?
A. Apply oxygen
B. Notify the provider
C. Check calcium levels
D. Reassure the client
Tingling is a sign of hypocalcemia, which is common after thyroid surgery
due to parathyroid injury.
8. Which nursing action is a priority in the care of a burn patient in the
emergent phase?
A. Administer pain medications
B. Initiate fluid resuscitation
C. Debride necrotic tissue
D. Apply topical antibiotics
, Fluid loss is massive in the emergent phase; restoring perfusion is the
priority.
9. A client with cirrhosis is receiving lactulose. What is the desired outcome?
A. Decreased ammonia level
B. Increased potassium level
C. Decreased bilirubin level
D. Improved mental status
Lactulose helps reduce ammonia levels, improving hepatic
encephalopathy symptoms.
10.A client is scheduled for a colonoscopy. Which finding must be reported to
the provider before the procedure?
A. Hemorrhoids
B. Platelet count 75,000/mm³
C. Family history of colon cancer
D. Age over 50
Low platelets increase bleeding risk during biopsy or polypectomy.
11.Which of the following is a priority intervention for a patient with diabetic
ketoacidosis (DKA)?
A. Administer potassium
B. Begin IV fluid resuscitation
C. Give subcutaneous insulin
D. Administer sodium bicarbonate
Fluid replacement is the first step in correcting DKA to restore perfusion.
CARE III FINAL EXAM QUESTIONS AND
CORRECT DETAILED ANSWERS PLUS
RATIONALES 2025 RASMUSSEN UNIVERSITY
1. A nurse is caring for a client with a C6 spinal cord injury. Which finding
requires immediate intervention?
A. Flaccid paralysis of lower extremities
B. Warm, flushed skin and bradycardia
C. Blood pressure 80/50 mm Hg and heart rate 120 bpm
D. Loss of sensation below the level of injury
A low blood pressure and high heart rate indicate neurogenic shock,
which is life-threatening and requires immediate action.
2. Which lab value is most critical to monitor in a client receiving furosemide?
A. Hemoglobin
B. Sodium
C. Potassium
D. Creatinine
, Furosemide is a loop diuretic that can cause hypokalemia, increasing the
risk for cardiac dysrhythmias.
3. A nurse is reviewing medication orders for a client with increased
intracranial pressure. Which medication should the nurse question?
A. Morphine sulfate IV
B. Mannitol IV
C. Dexamethasone IV
D. Hypertonic saline IV
Morphine can cause respiratory depression and CO2 retention, leading to
vasodilation and increased ICP.
4. A client is in septic shock. Which finding indicates effective fluid
resuscitation?
A. Decreased urine output
B. Mean arterial pressure (MAP) >65 mm Hg
C. Increased lactate level
D. Cold, clammy skin
MAP above 65 mm Hg indicates adequate organ perfusion and effective
fluid resuscitation.
5. A nurse is assessing a client with a chest tube. Which finding should be
reported immediately?
A. Intermittent bubbling in the suction chamber
B. Continuous bubbling in the water-seal chamber
C. No drainage in the collection chamber for 2 hours
D. Drainage of 30 mL/hr
, Continuous bubbling in the water-seal chamber indicates an air leak and
must be reported.
6. Which assessment finding is expected in a client with left-sided heart
failure?
A. Jugular vein distention
B. Crackles in lungs
C. Peripheral edema
D. Ascites
Left-sided heart failure leads to pulmonary congestion, resulting in
crackles.
7. A client post-thyroidectomy reports tingling in the fingers. What is the
priority action?
A. Apply oxygen
B. Notify the provider
C. Check calcium levels
D. Reassure the client
Tingling is a sign of hypocalcemia, which is common after thyroid surgery
due to parathyroid injury.
8. Which nursing action is a priority in the care of a burn patient in the
emergent phase?
A. Administer pain medications
B. Initiate fluid resuscitation
C. Debride necrotic tissue
D. Apply topical antibiotics
, Fluid loss is massive in the emergent phase; restoring perfusion is the
priority.
9. A client with cirrhosis is receiving lactulose. What is the desired outcome?
A. Decreased ammonia level
B. Increased potassium level
C. Decreased bilirubin level
D. Improved mental status
Lactulose helps reduce ammonia levels, improving hepatic
encephalopathy symptoms.
10.A client is scheduled for a colonoscopy. Which finding must be reported to
the provider before the procedure?
A. Hemorrhoids
B. Platelet count 75,000/mm³
C. Family history of colon cancer
D. Age over 50
Low platelets increase bleeding risk during biopsy or polypectomy.
11.Which of the following is a priority intervention for a patient with diabetic
ketoacidosis (DKA)?
A. Administer potassium
B. Begin IV fluid resuscitation
C. Give subcutaneous insulin
D. Administer sodium bicarbonate
Fluid replacement is the first step in correcting DKA to restore perfusion.
