Download Rasmussen University NUR 2755 Exam 2 (pdf) | 2026/2027 | MDC 4 Q&A | Nursing and more Exams Nursing in PDF only on Docsity!
Rasmussen University NUR 2755 Exam 2 (pdf) | 2026/2027 | MDC 4 Q&A | Nursing
- A nurse is preparing a client for surgery. The client asks, "Why do I have to stay NPO after midnight?" Which response by the nurse is most accurate? A) "It prevents you from having to use the bathroom during surgery." B) "It reduces the risk of aspiration of stomach contents during anesthesia." C) "It ensures your stomach is empty for the surgical procedure." D) "It is a standard policy that applies to all surgical clients." Correct Answer: "It reduces the risk of aspiration of stomach contents during anesthesia." Rationale: The primary reason for NPO (nothing by mouth) status before surgery is to prevent aspiration of gastric contents during anesthesia induction. Aspiration can lead to severe pneumonia and other complications. Maintaining NPO status is a critical safety measure to protect the airway.
- A client is 24 hours postoperative following abdominal surgery. The nurse assesses the client and notes the wound edges are separating, and the client reports a feeling of "something giving way." The nurse should suspect which complication? A) Infection B) Dehiscence C) Evisceration D) Hematoma Correct Answer: Dehiscence Rationale: Dehiscence is the partial or complete separation of wound edges. The client may report a feeling of "something giving way," and the nurse
may observe the wound edges separating. Evisceration involves the protrusion of internal organs through the wound, which is a more severe complication. Prompt recognition and intervention are essential.
- A client is 48 hours postoperative and reports sudden shortness of breath, chest pain, and tachycardia. The nurse should suspect which complication? A) Atelectasis B) Pulmonary embolism C) Pneumonia D) Wound infection Correct Answer: Pulmonary embolism Rationale: Sudden shortness of breath, chest pain (often pleuritic), and tachycardia are classic signs of a pulmonary embolism (PE). A PE occurs when a clot (often from a DVT) lodges in the pulmonary vessels. Atelectasis and pneumonia typically present with fever and cough, and wound infection presents with localized signs.
- A client is being discharged home after surgery. Which instruction should the nurse include to prevent venous thromboembolism (VTE)? A) "Remain on bed rest for the first week." B) "Ambulate frequently and perform leg exercises." C) "Restrict fluid intake to prevent fluid overload." D) "Cross your legs when sitting to improve circulation." Correct Answer: "Ambulate frequently and perform leg exercises." Rationale: Early ambulation and leg exercises help prevent VTE by promoting venous return and preventing stasis. Bed rest, fluid restriction, and crossing
client, and notify the provider. Naloxone may be administered if ordered. The PCA should not be continued or increased.
- A client is postoperative and is at risk for atelectasis. Which nursing intervention is most effective in preventing this complication? A) Administering a bronchodilator B) Encouraging deep breathing and incentive spirometry C) Restricting oral fluids D) Placing the client in a supine position Correct Answer: Encouraging deep breathing and incentive spirometry Rationale: Deep breathing and incentive spirometry help expand the lungs and prevent atelectasis by promoting alveolar inflation and clearing secretions. Bronchodilators may help if bronchospasm is present, but deep breathing is the primary intervention.
- A confused client exhibits a blood pressure of 112/84 mm Hg, a pulse rate of 116 beats per minute, and respirations of 30 breaths per minute. The client's skin is cold and clammy. Which action should the nurse take next? A) Contact the admitting physician B) Call the Rapid Response Team C) Re-assess the vital signs D) Administer oxygen by nasal cannula at 2 L/min Correct Answer: Call the Rapid Response Team Rationale: The client is showing signs of shock (tachycardia, tachypnea, cold/clammy skin, confusion). The Rapid Response Team should be activated early to intervene before the client's status evolves into a medical
emergency. Criteria for activation include heart rate >140 or <40, respiratory rate >28 or <8, systolic BP >180 or <90, oxygen saturation <90%, acute change in mental status, and staff concern.
- A client is brought to the emergency department unresponsive, with an elevated temperature and flushed skin. Physical assessment reveals a rapid, bounding pulse. The client's workplace has had a significant increase in staphylococcal and streptococcal infections. Labs show an elevated white blood cell count. The nurse should suspect which type of shock? A) Cardiogenic shock B) Septic shock C) Anaphylactic shock D) Neurogenic shock Correct Answer: Septic shock Rationale: Septic shock is caused by infection and is characterized by fever, elevated WBC, flushed skin, and a rapid, bounding pulse. Cardiogenic shock is due to pump failure, anaphylactic shock is due to allergic reaction, and neurogenic shock is due to spinal cord injury.
- A client with septic shock is receiving vasopressors. Which medication is commonly used as a first-line vasopressor in septic shock? A) Norepinephrine B) Dobutamine C) Nitroprusside D) Epinephrine Correct Answer: Norepinephrine
support clients with cardiogenic shock. The balloon inflates during diastole and deflates during systole.
- A client is diagnosed with hypovolemic shock. Which intervention is a priority? A) Administering vasopressors B) Administering IV fluids C) Administering antibiotics D) Administering anticoagulants Correct Answer: Administering IV fluids Rationale: The priority in hypovolemic shock is to restore intravascular volume with IV fluids. Vasopressors may be used if fluid resuscitation is inadequate, antibiotics are for septic shock, and anticoagulants are not the primary treatment.
- A client is in the progressive stage of shock. Which arterial blood gas (ABG) finding would the nurse expect? A) pH 7.38, PaCO2 40 mm Hg, HCO3 24 mEq/L B) pH 7.30, PaCO2 35 mm Hg, HCO3 16 mEq/L C) pH 7.48, PaCO2 32 mm Hg, HCO3 26 mEq/L D) pH 7.36, PaCO2 42 mm Hg, HCO3 22 mEq/L Correct Answer: pH 7.30, PaCO2 35 mm Hg, HCO3 16 mEq/L Rationale: In the progressive stage of shock, anaerobic metabolism leads to metabolic acidosis, characterized by low pH (<7.35) and low HCO3 (<22). The PaCO2 may be low as the body attempts to compensate.
- The nurse is monitoring a client with a pulmonary artery catheter (Swan- Ganz). Which hemodynamic value reflects left ventricular preload? A) Central venous pressure (CVP) B) Pulmonary artery wedge pressure (PAWP) C) Cardiac output (CO) D) Systemic vascular resistance (SVR) Correct Answer: Pulmonary artery wedge pressure (PAWP) Rationale: PAWP (also called pulmonary artery occlusion pressure) reflects left atrial pressure and left ventricular end-diastolic volume (preload). CVP reflects right heart preload. CO measures cardiac function, and SVR reflects afterload.
- A client with septic shock is experiencing disseminated intravascular coagulation (DIC). The nurse should monitor for which complication? A) Bleeding and thrombosis B) Hypertension C) Hyperglycemia D) Bradycardia Correct Answer: Bleeding and thrombosis Rationale: DIC is a disorder of coagulation that results in both widespread clotting and severe bleeding. The nurse should monitor for signs of bleeding (petechiae, oozing) and thrombosis (ischemia, organ failure).
A) Hypertension and tachycardia B) Hypotension and bradycardia C) Hypertension and bradycardia D) Hypotension and tachycardia Correct Answer: Hypotension and bradycardia Rationale: Neurogenic shock is characterized by hypotension and bradycardia due to loss of sympathetic tone. Unlike other types of shock, neurogenic shock causes bradycardia rather than tachycardia.
- A client is at risk for developing multiple organ dysfunction syndrome (MODS). Which condition is a common precursor to MODS? A) Hypertension B) Sepsis C) Hyperlipidemia D) Diabetes mellitus Correct Answer: Sepsis Rationale: Sepsis is a major risk factor for MODS. The systemic inflammatory response can lead to organ dysfunction and failure. Hypertension, hyperlipidemia, and diabetes are not direct precursors to MODS.
- The nurse is caring for a client with MODS. Which organ is most commonly affected first? A) Heart B) Lungs C) Kidneys
D) Liver Correct Answer: Lungs Rationale: The lungs are often the first organs affected in MODS, leading to acute respiratory distress syndrome (ARDS). The heart, kidneys, and liver may also be affected, but pulmonary dysfunction is typically the earliest manifestation.
- A client is in the compensation stage of shock. Which compensatory mechanism is activated? A) Parasympathetic nervous system B) Sympathetic nervous system C) Vagus nerve stimulation D) Baroreceptor inhibition Correct Answer: Sympathetic nervous system Rationale: In the compensation stage of shock, the sympathetic nervous system is activated to maintain blood pressure and perfusion. This causes vasoconstriction, increased heart rate, and increased cardiac contractility.
- The nurse is assessing a client with a pulmonary artery catheter. Which hemodynamic parameter reflects afterload? A) Cardiac output B) Pulmonary artery wedge pressure (PAWP) C) Central venous pressure (CVP) D) Systemic vascular resistance (SVR)
Rationale: Hypercapnic respiratory failure is characterized by elevated CO levels and presents with decreased level of consciousness, drowsiness, confusion, headache, lethargy, and seizures. Hypoxemic failure presents with restlessness and tachycardia.
- A client with acute respiratory distress syndrome (ARDS) is receiving mechanical ventilation. Which nursing intervention is most important to prevent ventilator-associated pneumonia (VAP)? A) Suctioning the client every 2 hours B) Maintaining the head of the bed elevated at 30-45 degrees C) Restricting fluid intake D) Administering bronchodilators Correct Answer: Maintaining the head of the bed elevated at 30-45 degrees Rationale: Elevating the head of the bed to 30-45 degrees helps prevent ventilator-associated pneumonia (VAP) by reducing the risk of aspiration. Suctioning should be done as needed, not on a fixed schedule. Fluid management is important but not the primary intervention for VAP prevention.
- A client is diagnosed with ARDS. Which finding is most characteristic of this condition? A) Hypoxemia that improves with supplemental oxygen B) Refractory hypoxemia that does not improve with 100% oxygen C) Hypercapnia with normal oxygenation D) Sudden onset of wheezing
Correct Answer: Refractory hypoxemia that does not improve with 100% oxygen Rationale: ARDS is characterized by refractory hypoxemia, where the client remains hypoxemic even with 100% oxygen due to intrapulmonary shunting and ventilation-perfusion mismatch. This is a hallmark feature of ARDS.
- A client with a flail chest is at risk for which complication? A) Pneumothorax B) Pulmonary contusion C) Hemothorax D) All of the above Correct Answer: All of the above Rationale: Flail chest is often associated with underlying lung injury, including pulmonary contusion, pneumothorax, and hemothorax. These complications can worsen respiratory status and require prompt intervention.
- A client with a tension pneumothorax is in severe respiratory distress. Which intervention should the nurse anticipate? A) Chest tube insertion at the 2nd intercostal space B) Needle decompression at the 2nd intercostal space midclavicular line C) Chest tube insertion at the 4th intercostal space D) Oxygen therapy via non-rebreather mask Correct Answer: Needle decompression at the 2nd intercostal space midclavicular line
- A client with a chest tube has tidaling in the water seal chamber. The nurse should: A) Clamp the chest tube B) Document this as a normal finding C) Notify the healthcare provider immediately D) Increase the suction pressure Correct Answer: Document this as a normal finding Rationale: Tidaling (fluctuation) in the water seal chamber with respiration is a normal finding that indicates the chest tube is functioning properly. It reflects pressure changes in the pleural space with breathing.
- A client with a pulmonary embolism is receiving anticoagulation therapy. Which laboratory value should the nurse monitor for heparin therapy? A) Prothrombin time (PT) B) International normalized ratio (INR) C) Activated partial thromboplastin time (aPTT) D) Platelet count Correct Answer: Activated partial thromboplastin time (aPTT) Rationale: Heparin therapy is monitored using the activated partial thromboplastin time (aPTT). The therapeutic goal is typically 1.5 to 2.5 times the normal control value. PT and INR monitor warfarin therapy.
- A client with a pulmonary embolism is prescribed warfarin. The nurse should monitor which laboratory value? A) Activated partial thromboplastin time (aPTT)
B) International normalized ratio (INR) C) Platelet count D) Serum sodium Correct Answer: International normalized ratio (INR) Rationale: Warfarin therapy is monitored using the International Normalized Ratio (INR), with a therapeutic range typically between 2.0 and 3.0 for most indications. aPTT monitors heparin, platelet count monitors for HIT, and serum sodium is not directly related to warfarin.
- A client with a pulmonary embolism is at risk for which complication? A) Pneumothorax B) Hemorrhage C) Cardiac tamponade D) Pericarditis Correct Answer: Hemorrhage Rationale: Clients with a pulmonary embolism are often treated with anticoagulants, which increase the risk of hemorrhage. Pneumothorax, cardiac tamponade, and pericarditis are not typical complications of PE.
- The nurse is interpreting arterial blood gas (ABG) results for a client with respiratory distress. The results show pH 7.28, PaCO2 55 mm Hg, and HCO 24 mEq/L. The nurse should interpret this as: A) Metabolic acidosis B) Respiratory acidosis C) Metabolic alkalosis
Correct Answer: Decreased cardiac output Rationale: PEEP can decrease venous return and cardiac output, leading to hypotension. The nurse should monitor blood pressure and cardiac output closely.
- The nurse is caring for a client receiving mechanical ventilation. The nurse uses the DOPE mnemonic to assess for complications. What does the "O" in DOPE stand for? A) Oxygen B) Obstruction C) Overdistention D) Observation Correct Answer: Obstruction Rationale: The DOPE mnemonic is used to assess for complications in a client receiving mechanical ventilation: D - Displaced tube, O - Obstructed tube, P - Pneumothorax, E - Equipment failure.
- A client with a burn injury has a wound that is dry, leathery, and hard with eschar. Which type of burn does this describe? A) Superficial burn B) Superficial partial-thickness burn C) Deep partial-thickness burn D) Full-thickness burn Correct Answer: Full-thickness burn
Rationale: A full-thickness burn destroys the epidermis and dermis and appears leathery, dry, and hard with eschar. Superficial burns are red and painful, superficial partial-thickness burns have blisters, and deep partial- thickness burns are red and dry.
- A client with a burn injury has a wound that is red, painful, and blanches with pressure. There are no blisters. The nurse classifies this burn as: A) Superficial burn B) Superficial partial-thickness burn C) Deep partial-thickness burn D) Full-thickness burn Correct Answer: Superficial burn Rationale: A superficial burn (first-degree) damages only the epidermis. It is characterized by redness, pain, blanching with pressure, and no scarring. Superficial partial-thickness burns have blisters.
- A client with a burn injury has a wet, shiny appearance to the wound with blisters and edema. The nurse correctly identifies this as which type of burn? A) Superficial burn B) Superficial partial-thickness burn C) Deep partial-thickness burn D) Full-thickness burn Correct Answer: Superficial partial-thickness burn
