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NUR 2356 / NUR2356 Multidimensional Care I (MDC 1)
CJE (Latest 2026/2027 Update) | Rasmussen University |
Complete Study Guide | Verified Questions & Answers |
100% Correct Solutions | Grade A
Q: The nurse is caring for four clients. Which client should the nurse first?
Chest pain and sudden dyspnea (shortness of breath) are priority (possible Pulmonary Embolism/ myocardial infarction aka heart attack) this is an immediate threat to life.
Q: The nurse prepares to enter the room of a client with C. difficle diarrhea. What PPE is
required? Gloves and gown. (Mask are not routinely required unless the risk of splash.)
Q: The nurse is teaching an UAP/unlicensed assistive personnel about precautions. Which
statement shows understanding. Standard precautions require gloves whenever contact with blood/ bloody fluids may occur.
Q: The nurse is starting an IV on a client. After palpating the vein, what should the nurse do
next? Hand hygiene and clean gloves are required before inserting the IV.
Q: The nurse cares for a client on airborne precautions for tuberculosis. Which action is most
important? Negative-pressure room with N95 use is critical for TB; door closed and mask for transport also, but room type is key.
Q: The nurse is reinforcing teaching about fire safety. Which action comes first if a fire is
discovered in a client’s room? RACE: Rescue, Alarm, Contain, Extinguish.
Q: The nurse notes that the side rails are all up on a confused client’s bed. What is the best
action? All rails up can be considered a restraint; reduce to the least restrictive while maintaining safety.
Q: Which task can the nurse delegate to a UAP?
Standardized tasks such as finger-stick glucose and report results; RN handles teaching, assessment, evaluation.
Q: A client with a DVT suddenly complains of sharp chest pain and shortness of breath. What
is the priority action? Suspected pulmonary embolism → position and oxygen first, then notify provider.
Q: The nurse hears wheezing in a client with asthma. Which medication does the nurse expect
to give first? Short-acting bronchodilator is the rescue medication for acute wheezing.
Q: A post-op client is receiving 2 L O₂ via nasal cannula and reports incisional pain 8/10. SpO₂
94%, RR 18. What action is best? Give prescribed opioid as ordered
Q: The nurse identifies which finding as an early sign of hypoxia?
Restlessness and anxiety
Q: Which position is best to improve oxygenation in a client with shortness of breath?
High Fowler's maximizes lung expansion.
Q: The nurse notes an irregular heartbeat and new onset dizziness in a client. What is the
priority assessment? Obtain vital signs and apical pulse
Q: A client reports chest pain. Which question should the nurse ask first?
"Where is the pain and does it radiate?"
Q: Which finding in a client with IV normal saline at 150 mL/hr is most concerning?
New crackles in lung bases (Crackles may indicate fluid overload from high IV rate.)
Bounding pulse and weight gain occur with excess fluid. A client with diabetes is diaphoretic, shaky, and confused. What is the priority action? Check blood glucose Signs of hypoglycemia → check glucose immediately. The nurse cares for a client with blood glucose 42 mg/dL who is awake and able to swallow. What is the best action? Give 4 oz juice Conscious and able to swallow → give fast-acting carbs. A client with type 2 diabetes reports numbness in both feet. Which intervention is most important? Teach daily foot inspection (Peripheral neuropathy → risk for injury; daily foot checks are critical.) The nurse reviews labs for a client: Na 128, K 4.0, BUN 16. Which is priority?
Restrict fluids (Hyponatremia often treated with fluid restriction unless otherwise ordered.) The nurse cares for an older adult on bedrest. What intervention is most important to prevent DVT? Encourage ankle pumps and leg exercises (Leg exercises promote venous return and reduce DVT risk.) The nurse turns a bedridden client every 2 hours. What is the primary reason for this intervention? Repositioning prevents pressure injuries. A client with a hip fracture is ordered to be non–weight-bearing. Which action requires intervention? Client uses walker and puts toe on the floor for balance (Non-weight-bearing means no weight on the extremity; even toe-touch should be clarified.)
A post-op client refuses to use the incentive spirometer because it hurts. What is the best response? "I'll premedicate you for pain and help you use it." (Treat pain and assist with use; it's important to prevent complications.) A client reports calf pain when walking that stops with rest. What is this finding most consistent with? Peripheral arterial disease (Intermittent claudication (pain with walking relieved by rest) is typical of PAD.) A post-op client has not voided in 8 hours. Bladder scan shows 650 mL. What is the priority action? Straight-catheterize per protocol The nurse is caring for a client with a Foley catheter. Which action prevents infection? Maintain closed system and keep bag below bladder
Which assessment is most important before giving furosemide? Blood pressure and potassium level (Loop diuretics can lower BP and K⁺; assess these before administration.) A client with constipation is prescribed stool softener and increased fiber. Which food is best? Fresh fruits and vegetables A client with diarrhea is at risk for what electrolyte imbalance? Hypokalemia (Potassium is lost through GI tract with diarrhea.) The nurse notes dark, tarry stools in a client. What is the term for this? Melena = black tarry stools from upper GI bleeding. A client taking opioids after surgery reports no bowel movement for 3 days. What is the best action?
The nurse is teaching about the use of a PCA pump. Which statement requires further teaching? "My family can push the button for me when I'm asleep." Only the patient should push the PCA button. A confused client tries to pull out IV lines. What is the best initial intervention? Move client closer to nurse's station and reorient The nurse cares for a client experiencing anxiety before surgery. What is the best response? "Tell me more about what is worrying you." Which finding suggests possible delirium in an older adult? Sudden confusion and disorganized thinking after surgery. (Delirium is acute and often after illness or surgery.) A client with depression states, “Nothing will ever get better.” What is the nurse’s priority? Ask directly if the client has thoughts of self-harm.
The nurse is teaching an older adult about new antihypertensive medication. What approach is best? Use large print handouts and simple language When using the teach-back method, the nurse should... Ask the client to repeat the instructions in their own words A client who speaks limited English is scheduled for surgery. Who should provide informed consent teaching? Professional medical interpreter The nurse suspects a client may be a victim of abuse. What is the priority action? Interview the client alone in a private setting Which client medication requires double-check by another nurse? Heparin IV infusion
Which route has the fastest systemic absorption? Intravenous The nurse prepares to administer insulin lispro. When should the nurse give it in relation to meals? Immediately before or with meals The nurse is giving ear drops to an adult. How should the ear be positioned? Pull pinna up and back After giving an IM injection in the deltoid, the nurse documents the site as... Deltoid muscle, upper arm The nurse has four tasks. Which should be done first? Assess a new post-op client just arriving from PACU The nurse notes a potassium level of 6.2 mEq/L on a client. What is the priority action?
Place on a cardiac monitor Which client should the nurse see first at the start of shift? Client with new onset slurred speech The nurse receives report. Which task is appropriate to assign to LPN? Monitoring a stable client with chronic COPD. (LPN can monitor stable clients; RN handles initial assessment and teaching.) The nurse finds a client with a chest tube whose collection chamber is tipped over. What is the first action? Place chamber upright and assess for air leak. (Re-establish system and assess; do not clamp/remove without order.) The UAP reports a client’s BP is 80/50. What should the nurse do first? Recheck BP manually and assess client.
(Respiratory depression from opioids → naloxone immediately, then notify provider.) The nurse assesses four clients. Which finding is most concerning? Client with new unilateral weaknes A client with HF gains 5 lb in 3 days and has 2+ edema. What is the priority instruction? Restrict fluids and sodium as ordered A client receiving blood transfusion develops itching and hives. What is the priority action? Stop the transfusion and maintain IV with normal saline. The nurse teaches a client with HF about daily weights. Which statement shows correct understanding? "I'll weigh each morning after I urinate, using the same scale." A client with pneumonia is using an incentive spirometer incorrectly. What should the nurse instruct?
"Inhale slowly and deeply through the mouthpiece, then hold your breath." The client with COPD is on 2 L O₂ and has thick secretions. What nursing action is most helpful? Encourage increased fluid intake, if not contraindicated. A client admitted with dehydration now has clear lungs, BP 110/70, and good urine output. What is the best evaluation statement? "Client's fluid balance has improved." The nurse assesses a post-op client 6 hours after surgery. Which finding is most concerning? Saturated dressing with bright red blood A client with a new colostomy is tearful and refusing to look at the stoma. What is the best nursing response? "Tell me how you're feeling about your colostomy." The nurse prepares to discharge a client with HF. Which statement shows need for more teaching?
