Download NUR 2356 / NUR2356: Multidimensional Care I / MDC 1 Final Exam (2025 / 2026) - Rasmussen and more Exams Nursing in PDF only on Docsity!
Rasmussen College MDC 1 Final Exam
Questions and Answers (Verified Answers)
- The nurse is caring for a 65-year-old client and notes a temperature of 101Fæ.how does the nurse interpret this finding
ANS Hyperthermia
- What is true about antiretroviral drugs used to treat human immunodeficien-cy virus (HIV)
ANS These drugs inhibit viral replication
- What is not an expected assessment finding in a client with inflammationon ? (Select all that apply) ANS Polyuria
- A client does not understand why vision loss due to glaucoma is irre- versible. What is the nurse's best explanation
ANS Once the tissue has necrosedfrom high-pressure, it does not regenerate
- The nurse is teaching a client with debilitatng rheumatoid arthritis abouthome safety. Which statement should the nurse include
ANS There are many adaptive devices and adaptive silverware available that may help you."
- A client is in the emergency room in critical condition and hypotensive. Her spouse is distraught. What is the priority nursing action
ANS Maintain the clientsblood pressure
- What level of Maslow's Hierarchy of needs does shelter belong to
ANS Physio-logical
- A nurse is teaching a client how to follow a low-purine diet as prescribedby the provider for the management of gout. What statement by the client indicates a correct understanding of the teaching
ANS How does this impact your role in your family?
- A post-operative client with a sutured abdominal incision felt a sharp abdominal pain after having a bowel movement. Upon inspection, the nursenotices bowel protruding from the incision site. What does the nurse tell thephysician about the event
ANS The clients incision site has eviscerated
- Most adults with human immunodeficiency virus will exhibit which of thefollowing laboratory values
ANS Lower than normal number of CD4+ T-cells and CD8+ T-cells are normal
- A nurse is teaching a client who has fibromyalgia about strategies that might help reduce her symptoms. What should the nurse include in the clienteducation
ANS establish regular sleep pattern
- What are signs of inadequate perfusion
ANS Pallor in toes
- A nurse is caring for a client who has acute osteomyelitis. Which of thefollowing interventions is the nurse's priority
ANS Administer antibiotics to the client
- The client states, "Why am I getting protein supplements while I am healing from a
include when providing client education about this ANS In order to avoid flare-ups of Raynaud's disease, ensure you wear gloves in winter.
- Which client is at highest risk of compromised immunity ANS A client who justhad surgery
- Who organizes and publishes the National Patient Safety Goals ANS The JointCommission 27. The quality and risk nurse in the local hospital is performing a hospital survey on sentinel events. Which statements would the nurse use to best de-
scribe a sentinel event ANS An unexpected event involving death or serious physicalor psychological injury
- A nurse is providing teaching to an older client who has osteoarthritis that is affecting the knees. What statement by the client indicates a correctunderstanding of the teaching ANS I can use either heat or ice to help relieve thediscomfort
- The nurse is most concerned about which of these findings in a client withsystemic lupus erythematous ANS Urine output of 20mL/hour
- Which of the following statements by a client with human immunodeficien- cy virus (HIV) requires further teaching? (Select all that apply) ANS A. 'I can spreadthis through contact with surfaces, so i need to wear gloves in public.'
B. 'Because I have HIV, that means I'm an AIDS patient'
E. 'I can still have unprotected intercourse with my partner since he does not haveHIV.'
31. What lifestyle habits negatively affect skin integrity? (Select all that apply)-
ANS
Tattoos Smoking Tanning
- The nurse is preparing to administer medications to a client with os- teoarthritis. What is the goal of medication therapy
38. Where will the nurse collect the most reliable source of pain assessment?-
ANS From the client
- Which of the following would be the most appropriate goal for an elderly client with a nursing diagnosis of risk for injury after hip surgery ANS Client willremain free from falls throughout their hospital stay
- A provider has ordered a wound culture for a client with a non-healingwound. What is the nurse'sfirst action ANS Put on non-sterile gloves
- The client with rheumatoid arthritis is having her rheumatoid factor (RF)drawn while she is having a flare-up of the disease. Which result is seen in clients with rheumatoid arthritis ANS A positive Rheumatoid factor
- The nurse suspects a 3-year-old who is coughing vigorously has aspirateda small object. Which action should the nurse take ANS Encourage the child to continue coughing
- Dry skin (Xerosis) can lead to itching (Pruritis). What statement by the client indicates need for further teaching about preventing dry skin ANS I willshower every day in hot water
- What is not appropriate client education on the preventing the spread of methicillin-resistance Staphylococcus aureus (MRSA) ANS Use a bath sponge tocleanse the skin
- A nurse enters the hospital room of a client with reduced immunity. What observation requires further action by the nurse
ANS The client has a vase of freshflowers on the table
46. A client is post-operative day 1 and reports a sudden increase in blood-tinged liquid draining from his incision after feeling a popping sensa- tion. What is the nurse's next action ANS Assess the wound for signs of dehiscence
- A client arrives speaking only Spanish. What is the priority nursing inter- vention ANS Request a medical interpreter
- what is a symptom of the expected disease pattern of rheumatoid arthri- tis ANS Bilateral Joint pain
- A client has cellulitis on his left arm. What statement by the client indicates understanding of symptom management ANS I can use a warm, moist towel on myarm
- Which of the following statements made by a client diagnosed with human immunodeficiency virus (HIV) would require further teaching ANS "I will only needto take HIV medications for 6 months, and I will be cured."
- What can the nurse teach the client with acquired immunodeficiency syn- drome (AIDS) to reduce the risk of infection? (Select all that apply) ANS Avoid rawfruits and vegetables
- A nurse is providing oral hygiene for an unconscious client. What is thepriority nursing intervention ANS Position the client on one side with their head turned towards you
- A client is experiencing numbness and tingling distal to a new arm cast with no increase in pain. The nurse assesses that the client's fingers are pale,cool and swollen. What action does the nurse take next ANS Raise the arm abovethe level of the heart
- The client asks the nurse what nonpharmacological intervention can be used to reduce pain and swelling in her joints affected by rheumatoid arthritis.What is the most appropriate response by the nurse ANS "Ice packs can be usedto reduce swelling but should be removed after 20 minutes."
- A nurse is preparing a community presentation about repetitive motioninjuries. Which of the following occupations should the nurse identify as increasing a client's risk for carpal tunnel syndrome ANS Assembly line worker
- A nurse is caring for an intubated and sedated geriatric client. What in-tervention is most appropriate for reducing the risk for a friction and shearinjury ANS Use a mechanical lift to reposition the client every 2 hours
- A client is in skeletal traction. With the nurse's assessment, it is noted that the pairs appear red, swollen and there is purulent drainage. What action does the nurse take first ANS collect a culture of the purulent fluid
- What nursing interventions decrease the risk the pressure injuries? (Selectall that apply) ANS Padding hard surfaces Place pillows between bony surfaces Keep HOB at or less than 30 degrees
- During a skin inspection at the outpatient clinic, the nurse notices patchesof thick, red skin with silvery scales on the client's elbows and knees. What skin abnormality does the nurse suspect ANS Psoriasis
- A nurse is teaching a client who has a new prescription for ibuprofen totreat rheumatoid arthritis. The nurse should teach the client to monitor for what adverse affect of this medication ANS Bleeding
- A client is bedridden and appears to be frail and malnourished. Which nursing interventions will decrease the risk of pressure injury? (Select all thatapply) ANS Applying moisturizer to dry areas of the skin Cleansing the skin after soiling Using a hoyer lifer for all transfers
- An area of erythema on the child's skin is being assessed by the nurse. The nurse presses down on the area, and the area becomes white. What time does the nurse document for this finding ANS Blanching
- Convert 60 ml to ounces. (Record as a whole number.) ANS 2
Heat for 20-30 mins Hot showers
- How many mL is one teaspoon ANS 5mL
- The nurse notices a new area of skin breakdown near the site of a dressing.This would be an example of which phase of the nursing process ANS Assess- ment
- A client is recovering from a fractured radius that occurred 7 weeks ago. Which state of bone healing occurs at this time as the callus is restored and transformed into bone ANS Stage 4
- What nursing intervention is best to improve communication with a hear- ing- impaired client ANS Speak slowly and clearly while facing the client
- A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse prepares to enter the room to check the client's pulse. What personal protective equipment (PPE) should the nurse don ANS Gown
- The client with systemic sclerosis (Scleroderma) is experiencing Ray- naud's phenomenon. What assessment finding does the nurse anticipate ANS -Cold and purple nail beds
- What are some of the expected outcomes when medications are given for rheumatoid arthritis? (Select all that apply) ANS Increased quality of life
Increased ROM Decreased pain Reduced inflammation
- The nurse assesses a deep wound. The area is covered by black andnecrotic tissue. What term would the nurse use when documenting thiswound ANS Eschar
- A client has AIDS. Which of these assessment findings indicate possibleinfection? (Select all that apply) ANS Respirations ANS 22 Purulent drainage Temp 101.
- A wound has a blood-tinged liquid that is dripping from the surgical site. How does the nurse document this finding ANS Serosanguineous 88. What steps are included in preparing a sterile field? (Select all that apply)-
ANS A. Do not turn away from the sterile field C. Prepare the client before setting up the sterile field D. Cover the sterilefield once it is set up E. Add items to the sterile field by dropping them gently
89. The nurse is caring for a client who develops compartment syndrome from a severely fractured arm.The client asks how this can happen. What is the best
ANS Culture the wound Assess the wound and assess the drainage
- What is a classic symptom assessed in clients with lupus ANS Butterfly rash
- The 65-year-old male client who is complaining of blurred vision reports he thinks his glasses need to be cleaned all the time and he denies any type of eye pain. Which eye disorder should the nurse suspects the clients has ANS Cataracts
- What is the likely reason that a client with acquired immunodeficiency syn- drome (AIDS) would succumb to pneumonia while a healthy person exposed to the same infection did not ANS The client with AIDS is a susceptible host
- A nurse assesses an area of skin over a bony prominence. What finding would be most concerning ANS Redness Non-Blanching
- A client who is sitting in High-Fowler's position is at risk for what type of injury as the skin layers shift in opposite directions ANS Shearing Injury
- What statement by the client indicates a correct understanding of thetiming of progression of human immunodeficiency virus (HIV) to acquired immunodeficiency syndrome ANS "If I am re-exposed to HIV, the progression toAIDS may be faster."
- When providing a routine bed bath, what ac)on does the nurse complete first ANS Cleanse the clients face
- The mother of a newborn baby is concerned that the baby will develop illnesses from being around people from outside of their family. What is the nurse's best response ANS "Tell me more about that."
- A client has an abdominal incision. The surgical wound was closed with10 sutures. This surgical wound is healing by what process ANS Primary Intention
- What should the nurse do first if they are stuck by a needle ANS Flush theexposed skin with water
- A nurse is admitting a client who has tuberculosis. What transmis-sion- based precautions should the nurse initiate ANS Airborne
- The nurse is caring for 4 clients, Which of these clients will the nurse seefirst ANS A client with sudden and increasing pain in his fractured arm.
- The client is at risk for impaired skin integrity related to the need for several weeks of bedrest.The nurse evaluates the client after 1 week and findsskin integrity is not impaired. In evaluating the plan of care, what is the nurse'sbest action ANS Keep the nursing diagnosis in the plan of care the same since the riskfactors are still present
- What are the causes of a pressure ulcer ANS ImmobilityPoor nutrition Moisture
