1
NUR 2356 Multidimensional
Care I Final Exam 2025 –
Actual Exam Questions with
100% Verified Answers |
MDC 1 Review | Rasmussen
College
1. A nurse is assessing a client with a suspected pressure ulcer. Which of the following
is an extrinsic risk factor for pressure ulcer development?
A) Poor nutrition
B) Friction
C) Impaired mobility
D) Age
B) Friction
Rationale: Friction is an extrinsic risk factor for pressure ulcers, as it causes shear stress
on the skin, contributing to tissue breakdown. Poor nutrition (A), impaired mobility (C),
and age (D) are intrinsic factors.
2. A nurse is caring for a client with a fever of 101°F. How should the nurse interpret
this finding in a 65-year-old client?
A) Normal for age
B) Indicative of infection
C) Expected in elderly clients
D) Requires no intervention
B) Indicative of infection
Rationale: A fever of 101°F in a 65-year-old client suggests a possible infection, as
elderly clients may not mount a high fever response. This requires further assessment and
intervention. Normal temperature (A), expected finding (C), and no intervention (D) are
incorrect.
3. What is the priority nursing intervention for a client with an oxygen saturation of
88%?
A) Raise the head of the bed
, 2
B) Tell the client to rest
C) Notify the provider immediately
D) Encourage coughing
C) Notify the provider immediately
Rationale: An oxygen saturation of 88% indicates hypoxia, a medical emergency
requiring immediate provider notification to address the underlying cause and initiate
oxygen therapy if ordered. Raising the head of the bed (A) and encouraging coughing (D)
are secondary, and rest (B) does not address hypoxia.
4. A client with a stage 3 pressure ulcer has visible subcutaneous fat but no muscle or
bone exposure. What is the best nursing intervention?
A) Apply a dry dressing
B) Use a moist wound dressing
C) Leave the wound open to air
D) Apply a cold pack
B) Use a moist wound dressing
Rationale: A stage 3 pressure ulcer requires a moist wound dressing to promote healing
and prevent infection. Dry dressings (A) can adhere to tissue, open-to-air (C) risks
drying, and cold packs (D) are not appropriate.
5. Which of the following is a primary defense against infection?
A) Inflammation
B) Fever
C) Phagocytosis
D) Intact skin
D) Intact skin
Rationale: Intact skin is the body’s primary defense against infection, acting as a
physical barrier. Inflammation (A), fever (B), and phagocytosis (C) are secondary
defenses.
6. A nurse is planning care for a client on bed rest. Which intervention should be
included to prevent complications?
A) Restrict fluid intake
B) Encourage antiembolic exercises every 2 hours
C) Reposition every 4 hours
D) Limit coughing and deep breathing
B) Encourage antiembolic exercises every 2 hours
Rationale: Antiembolic exercises, such as ankle pumps, every 2 hours prevent venous
stasis and deep vein thrombosis in bedridden clients. Fluid restriction (A) risks
dehydration, repositioning every 4 hours (C) is too infrequent, and limiting coughing (D)
increases pneumonia risk.
7. A client with pneumonia is experiencing hypoxia. What is the priority nursing
action?
A) Administer oxygen as prescribed
B) Encourage fluid intake
C) Teach deep breathing exercises
D) Monitor temperature
A) Administer oxygen as prescribed
Rationale: Hypoxia requires immediate oxygen administration to restore adequate
, 3
oxygenation. Fluid intake (B), deep breathing (C), and temperature monitoring (D) are
secondary interventions.
8. Which assessment finding indicates a client is at risk for impaired skin integrity?
A) Normal BMI
B) Incontinence
C) Good hydration
D) Active lifestyle
B) Incontinence
Rationale: Incontinence increases the risk of skin breakdown due to moisture exposure.
Normal BMI (A), good hydration (C), and an active lifestyle (D) reduce risk.
9. A nurse is teaching a client about wound care. Which statement indicates
understanding of infection prevention?
A) “I’ll clean the wound with alcohol daily.”
B) “I’ll use a clean washcloth and water to clean the wound.”
C) “I’ll leave the wound open to air.”
D) “I’ll apply lotion to the wound bed.”
B) “I’ll use a clean washcloth and water to clean the wound.”
Rationale: Using a clean washcloth and water promotes gentle cleansing without
damaging tissue. Alcohol (A) is too harsh, open-to-air (C) risks drying, and lotion (D)
can introduce contaminants.
10. What is a common complication of untreated pain in a postoperative client?
A) Faster recovery
B) Depression
C) Weight gain
D) Improved mobility
B) Depression
Rationale: Untreated pain can lead to depression, anxiety, and slower healing. Faster
recovery (A), weight gain (C), and improved mobility (D) are not associated with
untreated pain.
11. A nurse is assessing a client with suspected Sjogren’s syndrome. Which symptom is
NOT associated with this condition?
A) Dry mouth
B) Dry eyes
C) Increased energy
D) Joint pain
C) Increased energy
Rationale: Sjogren’s syndrome causes dry mouth, dry eyes, and joint pain due to
autoimmune effects on moisture-producing glands. Increased energy is not a symptom;
fatigue is more common.
12. A client with a suspected fracture is brought to the emergency department. What is
the priority nursing action?
A) Administer pain medication
B) Check for pulses
C) Apply a splint
D) Educate on cast care
B) Check for pulses
, 4
Rationale: Checking pulses assesses circulation, a priority to detect complications like
compartment syndrome. Pain medication (A), splinting (C), and education (D) are
secondary.
13. A nurse is caring for a client with a stage 4 pressure ulcer. Which finding should the
nurse expect?
A) Intact skin with redness
B) Visible muscle or bone
C) Superficial skin loss
D) Subcutaneous fat exposure
B) Visible muscle or bone
Rationale: Stage 4 pressure ulcers involve full-thickness tissue loss with visible muscle,
bone, or tendon. Intact skin (A) is stage 1, superficial loss (C) is stage 2, and
subcutaneous fat (D) is stage 3.
14. Which test is used to diagnose glaucoma?
A) Snellen Eye Chart
B) Tonometry
C) Corneal staining
D) Angiography
B) Tonometry
Rationale: Tonometry measures intraocular pressure to diagnose glaucoma. Snellen chart
(A) assesses visual acuity, corneal staining (C) evaluates corneal damage, and
angiography (D) is unrelated.
15. A nurse is teaching a client about antiembolic stockings. When should the client
remove them?
A) During bathing
B) At bedtime
C) Every 12 hours
D) Once daily for 2 hours
A) During bathing
Rationale: Antiembolic stockings should be removed during bathing to assess skin and
ensure hygiene, then reapplied promptly. Bedtime (B), every 12 hours (C), or once daily
(D) removal is not standard.
16. What is the priority assessment for a client with AIDS and Pneumocystis jirovecii
pneumonia (PCP)?
A) Oxygen saturation
B) Blood pressure
C) Temperature
D) Weight
A) Oxygen saturation
Rationale: PCP causes severe respiratory distress, making oxygen saturation the priority
assessment to monitor hypoxia. Blood pressure (B), temperature (C), and weight (D) are
secondary.
17. A nurse is caring for a client with a new colostomy. Which intervention promotes
adaptation?
A) Limit client participation in care
B) Teach stoma assessment and care
NUR 2356 Multidimensional
Care I Final Exam 2025 –
Actual Exam Questions with
100% Verified Answers |
MDC 1 Review | Rasmussen
College
1. A nurse is assessing a client with a suspected pressure ulcer. Which of the following
is an extrinsic risk factor for pressure ulcer development?
A) Poor nutrition
B) Friction
C) Impaired mobility
D) Age
B) Friction
Rationale: Friction is an extrinsic risk factor for pressure ulcers, as it causes shear stress
on the skin, contributing to tissue breakdown. Poor nutrition (A), impaired mobility (C),
and age (D) are intrinsic factors.
2. A nurse is caring for a client with a fever of 101°F. How should the nurse interpret
this finding in a 65-year-old client?
A) Normal for age
B) Indicative of infection
C) Expected in elderly clients
D) Requires no intervention
B) Indicative of infection
Rationale: A fever of 101°F in a 65-year-old client suggests a possible infection, as
elderly clients may not mount a high fever response. This requires further assessment and
intervention. Normal temperature (A), expected finding (C), and no intervention (D) are
incorrect.
3. What is the priority nursing intervention for a client with an oxygen saturation of
88%?
A) Raise the head of the bed
, 2
B) Tell the client to rest
C) Notify the provider immediately
D) Encourage coughing
C) Notify the provider immediately
Rationale: An oxygen saturation of 88% indicates hypoxia, a medical emergency
requiring immediate provider notification to address the underlying cause and initiate
oxygen therapy if ordered. Raising the head of the bed (A) and encouraging coughing (D)
are secondary, and rest (B) does not address hypoxia.
4. A client with a stage 3 pressure ulcer has visible subcutaneous fat but no muscle or
bone exposure. What is the best nursing intervention?
A) Apply a dry dressing
B) Use a moist wound dressing
C) Leave the wound open to air
D) Apply a cold pack
B) Use a moist wound dressing
Rationale: A stage 3 pressure ulcer requires a moist wound dressing to promote healing
and prevent infection. Dry dressings (A) can adhere to tissue, open-to-air (C) risks
drying, and cold packs (D) are not appropriate.
5. Which of the following is a primary defense against infection?
A) Inflammation
B) Fever
C) Phagocytosis
D) Intact skin
D) Intact skin
Rationale: Intact skin is the body’s primary defense against infection, acting as a
physical barrier. Inflammation (A), fever (B), and phagocytosis (C) are secondary
defenses.
6. A nurse is planning care for a client on bed rest. Which intervention should be
included to prevent complications?
A) Restrict fluid intake
B) Encourage antiembolic exercises every 2 hours
C) Reposition every 4 hours
D) Limit coughing and deep breathing
B) Encourage antiembolic exercises every 2 hours
Rationale: Antiembolic exercises, such as ankle pumps, every 2 hours prevent venous
stasis and deep vein thrombosis in bedridden clients. Fluid restriction (A) risks
dehydration, repositioning every 4 hours (C) is too infrequent, and limiting coughing (D)
increases pneumonia risk.
7. A client with pneumonia is experiencing hypoxia. What is the priority nursing
action?
A) Administer oxygen as prescribed
B) Encourage fluid intake
C) Teach deep breathing exercises
D) Monitor temperature
A) Administer oxygen as prescribed
Rationale: Hypoxia requires immediate oxygen administration to restore adequate
, 3
oxygenation. Fluid intake (B), deep breathing (C), and temperature monitoring (D) are
secondary interventions.
8. Which assessment finding indicates a client is at risk for impaired skin integrity?
A) Normal BMI
B) Incontinence
C) Good hydration
D) Active lifestyle
B) Incontinence
Rationale: Incontinence increases the risk of skin breakdown due to moisture exposure.
Normal BMI (A), good hydration (C), and an active lifestyle (D) reduce risk.
9. A nurse is teaching a client about wound care. Which statement indicates
understanding of infection prevention?
A) “I’ll clean the wound with alcohol daily.”
B) “I’ll use a clean washcloth and water to clean the wound.”
C) “I’ll leave the wound open to air.”
D) “I’ll apply lotion to the wound bed.”
B) “I’ll use a clean washcloth and water to clean the wound.”
Rationale: Using a clean washcloth and water promotes gentle cleansing without
damaging tissue. Alcohol (A) is too harsh, open-to-air (C) risks drying, and lotion (D)
can introduce contaminants.
10. What is a common complication of untreated pain in a postoperative client?
A) Faster recovery
B) Depression
C) Weight gain
D) Improved mobility
B) Depression
Rationale: Untreated pain can lead to depression, anxiety, and slower healing. Faster
recovery (A), weight gain (C), and improved mobility (D) are not associated with
untreated pain.
11. A nurse is assessing a client with suspected Sjogren’s syndrome. Which symptom is
NOT associated with this condition?
A) Dry mouth
B) Dry eyes
C) Increased energy
D) Joint pain
C) Increased energy
Rationale: Sjogren’s syndrome causes dry mouth, dry eyes, and joint pain due to
autoimmune effects on moisture-producing glands. Increased energy is not a symptom;
fatigue is more common.
12. A client with a suspected fracture is brought to the emergency department. What is
the priority nursing action?
A) Administer pain medication
B) Check for pulses
C) Apply a splint
D) Educate on cast care
B) Check for pulses
, 4
Rationale: Checking pulses assesses circulation, a priority to detect complications like
compartment syndrome. Pain medication (A), splinting (C), and education (D) are
secondary.
13. A nurse is caring for a client with a stage 4 pressure ulcer. Which finding should the
nurse expect?
A) Intact skin with redness
B) Visible muscle or bone
C) Superficial skin loss
D) Subcutaneous fat exposure
B) Visible muscle or bone
Rationale: Stage 4 pressure ulcers involve full-thickness tissue loss with visible muscle,
bone, or tendon. Intact skin (A) is stage 1, superficial loss (C) is stage 2, and
subcutaneous fat (D) is stage 3.
14. Which test is used to diagnose glaucoma?
A) Snellen Eye Chart
B) Tonometry
C) Corneal staining
D) Angiography
B) Tonometry
Rationale: Tonometry measures intraocular pressure to diagnose glaucoma. Snellen chart
(A) assesses visual acuity, corneal staining (C) evaluates corneal damage, and
angiography (D) is unrelated.
15. A nurse is teaching a client about antiembolic stockings. When should the client
remove them?
A) During bathing
B) At bedtime
C) Every 12 hours
D) Once daily for 2 hours
A) During bathing
Rationale: Antiembolic stockings should be removed during bathing to assess skin and
ensure hygiene, then reapplied promptly. Bedtime (B), every 12 hours (C), or once daily
(D) removal is not standard.
16. What is the priority assessment for a client with AIDS and Pneumocystis jirovecii
pneumonia (PCP)?
A) Oxygen saturation
B) Blood pressure
C) Temperature
D) Weight
A) Oxygen saturation
Rationale: PCP causes severe respiratory distress, making oxygen saturation the priority
assessment to monitor hypoxia. Blood pressure (B), temperature (C), and weight (D) are
secondary.
17. A nurse is caring for a client with a new colostomy. Which intervention promotes
adaptation?
A) Limit client participation in care
B) Teach stoma assessment and care
