NUR2356 Multidimensional Care I Exam 2 Quiz
Bank - Rasmussen College 2026-2027 |
Already Rated A | Nursing Fundamentals
Assessment
50 Application-Level Items with Clinical-Judgment Rationales
Domain 1 — Cardiovascular & Respiratory Management (≈18 Qs)
Q1
A patient admitted with acute MI 24 h ago has a heparin drip infusing via right femoral
sheath. Which assessment is the nurse’s priority?
A. Ask about chest discomfort
B. Observe for oozing at groin site
C. Auscultate heart sounds
D. Check pedal pulses q15 min
Correct: B
Rationale: Bleeding is the most immediate life-threatening complication of heparin,
especially at arterial access sites. Observing for oozing/hematoma (Recognize Cues →
,Safety) precedes other assessments. Chest discomfort (A) is important but not the first
risk related to drug effect.
Q2
A post-MI patient is prescribed sublingual nitroglycerin prn. Which instruction is most
important?
A. “Take up to 3 tablets 5 min apart.”
B. “Call 911 if pain unrelieved after 1 tablet.”
C. “Store tablets only in plastic bottles.”
D. “Drink water before dissolving.”
Correct: B
Rationale: Failure to relieve ischemic chest pain after 1 NTG = possible
extension/infarction → activate EMS (Generate Solutions). Sublingual route should be
dry (D wrong); 3-tablet rule (A) outdated for self-administration; glass bottle (C) prevents
breakdown.
Q3
A patient with acute HF has crackles to scapulae, SpO₂ 88 % on 4 L NC. Furosemide 80
mg IV push given. Which finding best indicates treatment effectiveness 30 min later?
A. Urine output 120 mL
B. SpO₂ 94 %
C. BP drop 10 mmHg
, D. Resp rate 24 from 32
Correct: D
Rationale: Most immediate evidence of decreased pulmonary congestion = improved
work of breathing (Evaluate Outcomes). O₂ sat (B) lags; UOP (A) helpful but slower; BP
change (C) not primary goal.
Q4
The nurse is caring for a COPD patient on 2 L NC. ABG: pH 7.28, PaCO₂ 65, PaO₂ 58.
Patient sleepy. What action first?
A. Increase O₂ to 4 L
B. Encourage incentive spirometry
C. Contact respiratory therapy for BiPAP
D. Obtain ABG in morning
Correct: C
Rationale: Acute hypercapnic respiratory failure (Analyze Cues) → non-invasive
ventilation to unload work of breathing. Increasing O₂ (A) risks further CO₂ narcosis; IS
(B) insufficient; waiting (D) unsafe.
Q5
An asthma patient uses fluticasone/salmeterol daily. Which statement shows correct
education?
A. “Use when I feel wheezy.”
Bank - Rasmussen College 2026-2027 |
Already Rated A | Nursing Fundamentals
Assessment
50 Application-Level Items with Clinical-Judgment Rationales
Domain 1 — Cardiovascular & Respiratory Management (≈18 Qs)
Q1
A patient admitted with acute MI 24 h ago has a heparin drip infusing via right femoral
sheath. Which assessment is the nurse’s priority?
A. Ask about chest discomfort
B. Observe for oozing at groin site
C. Auscultate heart sounds
D. Check pedal pulses q15 min
Correct: B
Rationale: Bleeding is the most immediate life-threatening complication of heparin,
especially at arterial access sites. Observing for oozing/hematoma (Recognize Cues →
,Safety) precedes other assessments. Chest discomfort (A) is important but not the first
risk related to drug effect.
Q2
A post-MI patient is prescribed sublingual nitroglycerin prn. Which instruction is most
important?
A. “Take up to 3 tablets 5 min apart.”
B. “Call 911 if pain unrelieved after 1 tablet.”
C. “Store tablets only in plastic bottles.”
D. “Drink water before dissolving.”
Correct: B
Rationale: Failure to relieve ischemic chest pain after 1 NTG = possible
extension/infarction → activate EMS (Generate Solutions). Sublingual route should be
dry (D wrong); 3-tablet rule (A) outdated for self-administration; glass bottle (C) prevents
breakdown.
Q3
A patient with acute HF has crackles to scapulae, SpO₂ 88 % on 4 L NC. Furosemide 80
mg IV push given. Which finding best indicates treatment effectiveness 30 min later?
A. Urine output 120 mL
B. SpO₂ 94 %
C. BP drop 10 mmHg
, D. Resp rate 24 from 32
Correct: D
Rationale: Most immediate evidence of decreased pulmonary congestion = improved
work of breathing (Evaluate Outcomes). O₂ sat (B) lags; UOP (A) helpful but slower; BP
change (C) not primary goal.
Q4
The nurse is caring for a COPD patient on 2 L NC. ABG: pH 7.28, PaCO₂ 65, PaO₂ 58.
Patient sleepy. What action first?
A. Increase O₂ to 4 L
B. Encourage incentive spirometry
C. Contact respiratory therapy for BiPAP
D. Obtain ABG in morning
Correct: C
Rationale: Acute hypercapnic respiratory failure (Analyze Cues) → non-invasive
ventilation to unload work of breathing. Increasing O₂ (A) risks further CO₂ narcosis; IS
(B) insufficient; waiting (D) unsafe.
Q5
An asthma patient uses fluticasone/salmeterol daily. Which statement shows correct
education?
A. “Use when I feel wheezy.”
