NUR2755 / NUR 2755 Final Exam (Latest ):
Multidimensional Care IV / MDC 4 - Rasmussen
Question 1
A nurse is performing a preoperative assessment on a client who states, "I'm so nervous about
this surgery; I'm afraid I won't wake up." Which nursing action is the most appropriate initial
response?
A) Inform the client that modern anesthesia is very safe and complications are rare.
B) Ask the client, "What about this surgery makes you most afraid?"
C) Notify the surgeon immediately to cancel the procedure.
D) Offer to administer a prescribed anxiolytic medication.
E) Document the client's anxiety in the medical record.
Correct Answer: B) Ask the client, "What about this surgery makes you most afraid?"
Rationale: This is the most therapeutic response. It uses an open-ended question to
encourage the client to verbalize their specific fears and concerns (Psychosocial). This
allows the nurse to perform a more focused psychosocial assessment and provide targeted
support. Reassuring with statistics (Option A) dismisses the client's feelings. Canceling the
surgery (Option C) is premature. Offering medication (Option D) may be appropriate later,
but assessing the fear is the priority first step. Documenting (Option E) is necessary, but it
is not a therapeutic intervention.
Question 2
A client is in the post-anesthesia care unit (PACU) following an abdominal hysterectomy. The
client is difficult to arouse, and their oxygen saturation is 88% on room air. What is the nurse's
priority action?
A) Administer a prescribed dose of naloxone.
B) Apply oxygen and perform a head-tilt, chin-lift maneuver.
C) Take the client's blood pressure and heart rate.
D) Stimulate the client by calling their name loudly.
E) Check the surgical dressing for signs of bleeding.
Correct Answer: B) Apply oxygen and perform a head-tilt, chin-lift maneuver.
Rationale: This is a prioritization of care question focused on oxygenation. An oxygen
saturation of 88% indicates hypoxemia. The most common cause of hypoxemia in the
,[Type here]
PACU is airway obstruction from the tongue relaxing in a sedated client. The priority
action is to address the ABCs (Airway, Breathing, Circulation). Performing a head-tilt,
chin-lift maneuver opens the airway, and applying supplemental oxygen directly treats the
hypoxemia. While other assessments are important, establishing a patent airway and
improving oxygenation is the immediate life-saving priority.
Question 3
A nurse is caring for a client in the emergent phase of a full-thickness burn covering 30% of their
total body surface area. The nurse should anticipate which fluid and electrolyte imbalance as the
most immediate threat?
A) Hypernatremia
B) Hypovolemic shock
C) Metabolic acidosis
D) Hyperkalemia
E) Hypocalcemia
Correct Answer: B) Hypovolemic shock
Rationale: During the emergent (resuscitative) phase of a major burn, a massive fluid shift
occurs where plasma moves from the intravascular space into the interstitial space (third-
spacing) due to increased capillary permeability (Inflammation, Fluid & Electrolyte). This
leads to a profound deficit in circulating blood volume, causing burn shock, a form of
hypovolemic shock. While electrolyte imbalances like hyperkalemia (from cell destruction)
occur, the massive fluid loss is the most immediate life-threatening concern.
Question 4
A client is admitted to the emergency department with suspected hypovolemic shock following a
traumatic injury. Which focused assessment finding is the most critical indicator of inadequate
organ perfusion?
A) Heart rate of 120 beats/minute.
B) Blood pressure of 100/70 mmHg.
C) Respiratory rate of 24 breaths/minute.
D) Capillary refill of 5 seconds.
E) Client reports feeling anxious and thirsty.
,[Type here]
Correct Answer: D) Capillary refill of 5 seconds.
Rationale: This question assesses the concept of perfusion. While tachycardia, tachypnea,
and anxiety are all signs of shock, a delayed capillary refill (>3 seconds) is a direct and
critical indicator of poor peripheral perfusion. It demonstrates that the cardiovascular
system is shunting blood away from the periphery to protect the vital core organs, signaling
a worsening state of shock.
Question 5
A postoperative client suddenly develops dyspnea, pleuritic chest pain, and anxiety. The vital
signs are: HR 125, BP 100/60, RR 28, SpO2 89%. The nurse should suspect which life-
threatening complication?
A) Pneumonia
B) Atelectasis
C) Pulmonary Embolism
D) Tension pneumothorax
E) Acute Respiratory Distress Syndrome (ARDS)
Correct Answer: C) Pulmonary Embolism
Rationale: The classic triad of symptoms for a pulmonary embolism (PE) is dyspnea, chest
pain, and hemoptysis, though not all are always present. The sudden onset of these
symptoms, combined with tachycardia, hypotension, and hypoxia in a postoperative client
(who is at high risk for DVT due to immobility), strongly points to a PE (Clotting,
Oxygenation & Gas Exchange). This is an emergency requiring immediate intervention.
Question 6
A nurse is assessing a client with a chest tube for a pneumothorax. Which finding would indicate
a tension pneumothorax is developing?
A) A respiratory rate of 20 breaths/minute.
B) Symmetrical chest wall movement.
C) Tracheal deviation toward the unaffected side.
D) Occasional bubbling in the water-seal chamber.
E) Decreased breath sounds over the affected lung.
, [Type here]
Correct Answer: C) Tracheal deviation toward the unaffected side.
Rationale: A tension pneumothorax is a medical emergency where air enters the pleural
space but cannot escape, causing a mediastinal shift. This increased pressure pushes the
trachea, heart, and great vessels toward the contralateral (unaffected) side. Tracheal
deviation is a hallmark and late sign of this life-threatening condition (Recognizing
Complications). Decreased breath sounds are expected with any pneumothorax, but
tracheal deviation signals a tension component.
Question 7
Which of the following pathophysiological changes is the primary characteristic of Acute
Respiratory Distress Syndrome (ARDS)?
A) Bronchoconstriction and mucus plugging.
B) Loss of lung elasticity due to alveolar wall destruction.
C) Increased pulmonary vascular resistance due to a blood clot.
D) Noncardiogenic pulmonary edema due to increased alveolar-capillary membrane
permeability.
E) Accumulation of air in the pleural space.
Correct Answer: D) Noncardiogenic pulmonary edema due to increased alveolar-capillary
membrane permeability.
Rationale: The defining feature of ARDS is diffuse injury to the alveolar-capillary
membrane (Inflammation). This injury makes the membrane leaky, allowing protein-rich
fluid to flood the alveoli. This is "noncardiogenic" because the edema is not caused by
heart failure. The fluid in the alveoli impairs gas exchange, leading to severe, refractory
hypoxemia.
Question 8
A nurse is admitting a client with a diagnosis of active pulmonary tuberculosis (TB). What is the
priority infection prevention measure the nurse must implement?
A) Place the client in a private room with contact precautions.
B) Wear a standard surgical mask when entering the client's room.
C) Initiate airborne precautions and place the client in a negative-pressure room.
Multidimensional Care IV / MDC 4 - Rasmussen
Question 1
A nurse is performing a preoperative assessment on a client who states, "I'm so nervous about
this surgery; I'm afraid I won't wake up." Which nursing action is the most appropriate initial
response?
A) Inform the client that modern anesthesia is very safe and complications are rare.
B) Ask the client, "What about this surgery makes you most afraid?"
C) Notify the surgeon immediately to cancel the procedure.
D) Offer to administer a prescribed anxiolytic medication.
E) Document the client's anxiety in the medical record.
Correct Answer: B) Ask the client, "What about this surgery makes you most afraid?"
Rationale: This is the most therapeutic response. It uses an open-ended question to
encourage the client to verbalize their specific fears and concerns (Psychosocial). This
allows the nurse to perform a more focused psychosocial assessment and provide targeted
support. Reassuring with statistics (Option A) dismisses the client's feelings. Canceling the
surgery (Option C) is premature. Offering medication (Option D) may be appropriate later,
but assessing the fear is the priority first step. Documenting (Option E) is necessary, but it
is not a therapeutic intervention.
Question 2
A client is in the post-anesthesia care unit (PACU) following an abdominal hysterectomy. The
client is difficult to arouse, and their oxygen saturation is 88% on room air. What is the nurse's
priority action?
A) Administer a prescribed dose of naloxone.
B) Apply oxygen and perform a head-tilt, chin-lift maneuver.
C) Take the client's blood pressure and heart rate.
D) Stimulate the client by calling their name loudly.
E) Check the surgical dressing for signs of bleeding.
Correct Answer: B) Apply oxygen and perform a head-tilt, chin-lift maneuver.
Rationale: This is a prioritization of care question focused on oxygenation. An oxygen
saturation of 88% indicates hypoxemia. The most common cause of hypoxemia in the
,[Type here]
PACU is airway obstruction from the tongue relaxing in a sedated client. The priority
action is to address the ABCs (Airway, Breathing, Circulation). Performing a head-tilt,
chin-lift maneuver opens the airway, and applying supplemental oxygen directly treats the
hypoxemia. While other assessments are important, establishing a patent airway and
improving oxygenation is the immediate life-saving priority.
Question 3
A nurse is caring for a client in the emergent phase of a full-thickness burn covering 30% of their
total body surface area. The nurse should anticipate which fluid and electrolyte imbalance as the
most immediate threat?
A) Hypernatremia
B) Hypovolemic shock
C) Metabolic acidosis
D) Hyperkalemia
E) Hypocalcemia
Correct Answer: B) Hypovolemic shock
Rationale: During the emergent (resuscitative) phase of a major burn, a massive fluid shift
occurs where plasma moves from the intravascular space into the interstitial space (third-
spacing) due to increased capillary permeability (Inflammation, Fluid & Electrolyte). This
leads to a profound deficit in circulating blood volume, causing burn shock, a form of
hypovolemic shock. While electrolyte imbalances like hyperkalemia (from cell destruction)
occur, the massive fluid loss is the most immediate life-threatening concern.
Question 4
A client is admitted to the emergency department with suspected hypovolemic shock following a
traumatic injury. Which focused assessment finding is the most critical indicator of inadequate
organ perfusion?
A) Heart rate of 120 beats/minute.
B) Blood pressure of 100/70 mmHg.
C) Respiratory rate of 24 breaths/minute.
D) Capillary refill of 5 seconds.
E) Client reports feeling anxious and thirsty.
,[Type here]
Correct Answer: D) Capillary refill of 5 seconds.
Rationale: This question assesses the concept of perfusion. While tachycardia, tachypnea,
and anxiety are all signs of shock, a delayed capillary refill (>3 seconds) is a direct and
critical indicator of poor peripheral perfusion. It demonstrates that the cardiovascular
system is shunting blood away from the periphery to protect the vital core organs, signaling
a worsening state of shock.
Question 5
A postoperative client suddenly develops dyspnea, pleuritic chest pain, and anxiety. The vital
signs are: HR 125, BP 100/60, RR 28, SpO2 89%. The nurse should suspect which life-
threatening complication?
A) Pneumonia
B) Atelectasis
C) Pulmonary Embolism
D) Tension pneumothorax
E) Acute Respiratory Distress Syndrome (ARDS)
Correct Answer: C) Pulmonary Embolism
Rationale: The classic triad of symptoms for a pulmonary embolism (PE) is dyspnea, chest
pain, and hemoptysis, though not all are always present. The sudden onset of these
symptoms, combined with tachycardia, hypotension, and hypoxia in a postoperative client
(who is at high risk for DVT due to immobility), strongly points to a PE (Clotting,
Oxygenation & Gas Exchange). This is an emergency requiring immediate intervention.
Question 6
A nurse is assessing a client with a chest tube for a pneumothorax. Which finding would indicate
a tension pneumothorax is developing?
A) A respiratory rate of 20 breaths/minute.
B) Symmetrical chest wall movement.
C) Tracheal deviation toward the unaffected side.
D) Occasional bubbling in the water-seal chamber.
E) Decreased breath sounds over the affected lung.
, [Type here]
Correct Answer: C) Tracheal deviation toward the unaffected side.
Rationale: A tension pneumothorax is a medical emergency where air enters the pleural
space but cannot escape, causing a mediastinal shift. This increased pressure pushes the
trachea, heart, and great vessels toward the contralateral (unaffected) side. Tracheal
deviation is a hallmark and late sign of this life-threatening condition (Recognizing
Complications). Decreased breath sounds are expected with any pneumothorax, but
tracheal deviation signals a tension component.
Question 7
Which of the following pathophysiological changes is the primary characteristic of Acute
Respiratory Distress Syndrome (ARDS)?
A) Bronchoconstriction and mucus plugging.
B) Loss of lung elasticity due to alveolar wall destruction.
C) Increased pulmonary vascular resistance due to a blood clot.
D) Noncardiogenic pulmonary edema due to increased alveolar-capillary membrane
permeability.
E) Accumulation of air in the pleural space.
Correct Answer: D) Noncardiogenic pulmonary edema due to increased alveolar-capillary
membrane permeability.
Rationale: The defining feature of ARDS is diffuse injury to the alveolar-capillary
membrane (Inflammation). This injury makes the membrane leaky, allowing protein-rich
fluid to flood the alveoli. This is "noncardiogenic" because the edema is not caused by
heart failure. The fluid in the alveoli impairs gas exchange, leading to severe, refractory
hypoxemia.
Question 8
A nurse is admitting a client with a diagnosis of active pulmonary tuberculosis (TB). What is the
priority infection prevention measure the nurse must implement?
A) Place the client in a private room with contact precautions.
B) Wear a standard surgical mask when entering the client's room.
C) Initiate airborne precautions and place the client in a negative-pressure room.
