Download Rasmussen University NUR 2755 Final Exam (pdf) | 2026/2027 | MDC 4 Q&A | Nursing and more Exams Nursing in PDF only on Docsity!
Rasmussen University NUR 2755 Final Exam (pdf) | 2026/2027 | MDC 4 Q&A | Nursing
- A nurse is caring for a client with increased intracranial pressure (ICP). Which nursing intervention is the priority? A) Encouraging frequent coughing and deep breathing B) Elevating the head of the bed to 30 degrees C) Administering hypotonic IV fluids D) Maintaining a quiet environment with minimal stimulation Correct Answer: Elevating the head of the bed to 30 degrees Rationale: Elevating the head of the bed to 30 degrees promotes venous drainage from the head and helps reduce ICP. While maintaining a quiet environment is important, it is not the primary intervention. Coughing and hypotonic fluids can increase ICP.
- A nurse is monitoring a client who had a thyroidectomy. Which assessment finding requires immediate intervention? A) Hoarseness B) Sore throat C) Laryngeal stridor D) Difficulty swallowing Correct Answer: Laryngeal stridor Rationale: Laryngeal stridor indicates airway obstruction and is a medical emergency following thyroidectomy. Hoarseness, sore throat, and difficulty swallowing are expected postoperative findings.
- A client with cirrhosis is at risk for hepatic encephalopathy. Which dietary modification should the nurse implement? A) Increase protein intake B) Limit carbohydrates C) Decrease protein intake D) Encourage high-sodium foods Correct Answer: Decrease protein intake Rationale: Protein breakdown leads to ammonia accumulation, which worsens hepatic encephalopathy. A low-protein diet is often recommended to reduce ammonia levels. Sodium should be restricted, not encouraged, in cirrhosis.
- Which laboratory value should the nurse monitor closely for a client receiving furosemide? A) Serum creatinine B) Serum potassium C) White blood cell count D) Hemoglobin Correct Answer: Serum potassium Rationale: Furosemide is a loop diuretic that can cause significant potassium loss, leading to hypokalemia. Potassium levels should be monitored closely. Creatinine and hemoglobin are not the primary concerns with furosemide.
- What is the priority nursing action for a client with a new tracheostomy and copious secretions?
Correct Answer: pH 7.48, PaCO2 44, HCO3 30 Rationale: Prolonged vomiting leads to loss of hydrochloric acid (HCl), causing metabolic alkalosis. This is characterized by an elevated pH (>7.45), elevated HCO3 (>26), and compensatory elevation in PaCO2.
- A client is diagnosed with a pulmonary embolism. Which assessment finding is most consistent with this condition? A) Bradycardia and hypotension B) Dyspnea, pleuritic chest pain, and tachycardia C) Fever and productive cough D) Wheezing and prolonged expiration Correct Answer: Dyspnea, pleuritic chest pain, and tachycardia Rationale: A pulmonary embolism (PE) typically presents with sudden dyspnea, pleuritic chest pain (sharp on inspiration), and tachycardia. A feeling of impending doom may also be present.
- A client with a flail chest is experiencing paradoxical chest movement. The nurse should prioritize which intervention? A) Administering pain medication B) Applying a chest binder C) Ensuring adequate oxygenation and ventilation D) Placing the client in a supine position Correct Answer: Ensuring adequate oxygenation and ventilation
Rationale: The priority in flail chest is maintaining adequate oxygenation and ventilation. Pain management is important, but the client is at risk for respiratory failure due to the paradoxical movement and underlying lung contusion.
- A client has a chest tube inserted for a pneumothorax. The nurse notes continuous bubbling in the water seal chamber. This finding indicates: A) Normal functioning of the chest tube B) An air leak C) The lung has re-expanded D) The chest tube is clogged Correct Answer: An air leak Rationale: Continuous bubbling in the water seal chamber indicates an air leak. Intermittent bubbling is normal and indicates air is being evacuated from the pleural space. Tidaling is also normal.
- The nurse is interpreting ABG results for a client in respiratory distress. The results show pH 7.28, PaCO2 55 mm Hg, and HCO3 24 mEq/L. The nurse should interpret this as: A) Metabolic acidosis B) Respiratory acidosis C) Metabolic alkalosis D) Respiratory alkalosis Correct Answer: Respiratory acidosis Rationale: The pH is low (<7.35), indicating acidosis. The PaCO2 is elevated (>45), indicating a respiratory cause. The HCO3 is within normal range (22-
- 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 full-thickness burn has eschar that appears black and leathery. The nurse understands that this eschar: A) Should be left in place to protect the wound B) May need to be removed surgically to prevent infection and promote healing C) Is a sign that the burn is healing properly D) Indicates that the burn is only superficial Correct Answer: May need to be removed surgically to prevent infection and promote healing Rationale: Eschar is dead tissue that forms over a full-thickness burn. It can become a source of infection and restrict circulation. Eschar may need to be removed surgically (escharotomy) to prevent infection and allow for healing.
- During the resuscitation phase of a burn injury, what is the primary focus of nursing care? A) Wound debridement and skin grafting B) Airway, breathing, circulation, and fluid replacement C) Nutritional support and high-calorie diet D) Physical therapy and rehabilitation Correct Answer: Airway, breathing, circulation, and fluid replacement Rationale: The resuscitation phase (first 24-48 hours) focuses on airway, breathing, circulation (ABCs), preventing infection, maintaining body temperature, and replacing fluid. Wound care and grafting occur later.
- The nurse is calculating fluid requirements using the Parkland Formula for a client with a 40% TBSA burn who weighs 70 kg. What is the total fluid requirement for the first 24 hours? A) 5,600 mL B) 8,400 mL C) 11,200 mL D) 14,000 mL Correct Answer: 11,200 mL Rationale: The Parkland Formula is 4 mL/kg/%TBSA burned. For a 70 kg client with 40% TBSA: 4 x 70 x 40 = 11,200 mL. Half is given in the first 8 hours, and the remainder over the next 16 hours.
- A client with a burn injury has a serum potassium level that is elevated. The nurse should monitor the client closely for which complication? A) Hypotension B) Dysrhythmias C) Seizures D) Hypothermia Correct Answer: Dysrhythmias Rationale: Potassium levels should be monitored in burn patients to prevent dysrhythmias. Hyperkalemia can lead to life-threatening cardiac dysrhythmias.
- A client with a burn injury has a wound that is being treated with silver sulfadiazine. The nurse should monitor for which side effect?
A) Leukopenia B) Hyperkalemia C) Hyponatremia D) Hyperglycemia Correct Answer: Leukopenia Rationale: Silver sulfadiazine is a topical antibiotic used for burn wounds. It can cause leukopenia (decreased white blood cell count) as a side effect.
- A client with a burn injury is being discharged home. Which instruction should the nurse include in the discharge teaching? A) "You can stop wound care once the burn is healed." B) "Wear sunscreen and protective clothing to protect the healed skin from sun damage." C) "You can resume all normal activities immediately." D) "You do not need to follow up with the burn clinic." Correct Answer: "Wear sunscreen and protective clothing to protect the healed skin from sun damage." Rationale: Healed burn skin is sensitive to sun damage and should be protected with sunscreen and protective clothing. The client should continue wound care as prescribed and follow up with the burn clinic.
- Following a serious thermal burn, which complication will the nurse take action to prevent first? A) Tissue hypoxia B) Infection
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 confused client has a blood pressure of 112/84 mm Hg, pulse 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.
- 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 Rationale: Norepinephrine is the first-line vasopressor in septic shock. It causes vasoconstriction and increases blood pressure. Dobutamine is an inotrope, nitroprusside is a vasodilator, and epinephrine may be used in anaphylactic shock.
- A client with cardiogenic shock is receiving an intra-aortic balloon pump (IABP). The nurse understands that this device works by: A) Increasing afterload B) Decreasing coronary artery perfusion C) Increasing cardiac output D) Decreasing myocardial oxygen demand Correct Answer: Increasing cardiac output Rationale: An intra-aortic balloon pump (IABP) increases cardiac output by decreasing afterload and increasing coronary artery perfusion. It is used to support clients with cardiogenic shock.
- 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: 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).
- In the treatment of shock, which vasoactive drug results in reduced preload and afterload, reducing oxygen demand of the heart? A) Nitroprusside B) Dopamine C) Methoxamine D) Epinephrine Correct Answer: Nitroprusside Rationale: Nitroprusside is a vasodilator that reduces both preload and afterload, decreasing the oxygen demand of the heart. Dopamine and epinephrine are vasopressors that increase afterload.
- The nurse is caring for a client with obstructive shock. Which condition is a common cause of obstructive shock? A) Myocardial infarction B) Cardiac tamponade C) Anaphylaxis D) Sepsis Correct Answer: Cardiac tamponade Rationale: Obstructive shock is caused by physical obstruction of blood flow. Cardiac tamponade, pulmonary embolism, and tension pneumothorax are common causes. Myocardial infarction causes cardiogenic shock.
- The nurse is assessing a client with neurogenic shock. Which finding is most consistent with this condition? 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 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.
- 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 legs increase the risk of VTE.
- A client is postoperative and has a surgical wound that is red, swollen, and has purulent drainage. Which action should the nurse take?
A) Clean the wound with sterile saline B) Notify the healthcare provider C) Apply a warm compress D) Document the finding and continue to monitor Correct Answer: Notify the healthcare provider Rationale: Redness, swelling, and purulent drainage are signs of a wound infection. The nurse should notify the healthcare provider for further orders, which may include wound culture and antibiotics.
- A client is receiving patient-controlled analgesia (PCA) for postoperative pain. The client is somnolent and has a respiratory rate of 8 breaths per minute. Which action should the nurse take? A) Administer naloxone B) Discontinue the PCA and notify the provider C) Increase the PCA dose D) Stimulate the client to wake up Correct Answer: Discontinue the PCA and notify the provider Rationale: The client is experiencing respiratory depression, which can be caused by opioid overdose. The nurse should discontinue the PCA, assess the client, and notify the provider. Naloxone may be administered if ordered.
- 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
