NUR 2502 / NUR2502 Final Exam (Latest
): Multidimensional Care III /
MDC 3 - Rasmussen
Q1: The nurse is caring for a client with heart failure who reports sudden onset of a dry,
persistent cough. Which diagnostic finding should the nurse anticipate correlating with this
symptom?
A. Brain natriuretic peptide (BNP) of 50 pg/mL
B. Chest X-ray showing pulmonary edema
C. Echocardiogram showing left ventricular hypertrophy
D. Electrocardiogram showing atrial fibrillation
Correct Answer: B
Rationale: Correct because a dry, persistent cough in heart failure is a classic sign of pulmonary
congestion, which correlates with pulmonary edema on a chest X-ray.
Q2: A client with left-sided heart failure asks why they are experiencing weight gain despite
having a poor appetite. What is the nurse's best response?
A. "Heart failure causes your body to store extra fat due to slowed metabolism."
B. "Your kidneys are retaining sodium and water, which builds up in your tissues."
C. "Poor appetite leads to decreased calorie burn, causing rapid weight gain."
D. "The medications you are taking increase your blood sugar and cause water retention."
Correct Answer: B
Rationale: Correct because decreased cardiac output in left-sided heart failure activates the
renin-angiotensin-aldosterone system, causing sodium and water retention that manifests as
weight gain.
,Q3: The nurse is reviewing the laboratory results for a client admitted with an acute myocardial
infarction (MI). Which biomarker is the most specific indicator of myocardial muscle damage?
A. Creatine kinase-MB (CK-MB)
B. High-sensitivity troponin I
C. Myoglobin
D. C-reactive protein (CRP)
Correct Answer: B
Rationale: Correct because high-sensitivity troponin I is highly specific to cardiac muscle and
rises within hours of myocardial injury, making it the gold standard for diagnosing an acute MI.
Q4: A client 2 days post-MI develops chest pain, shortness of breath, and a friction rub on
auscultation. Which complication should the nurse suspect?
A. Ventricular aneurysm
B. Cardiac tamponade
C. Pericarditis
D. Dressler syndrome
Correct Answer: C
Rationale: Correct because a pericardial friction rub accompanied by chest pain in the early
post-MI period is the hallmark sign of acute pericarditis.
Q5: The nurse is preparing to administer metoprolol to a client with hypertension. Which
assessment finding would prompt the nurse to hold the medication and contact the provider?
A. Blood pressure of 156/94 mmHg
B. Respiratory rate of 18 breaths/min
C. Heart rate of 48 bpm
D. Oxygen saturation of 95% on room air
,Correct Answer: C
Rationale: Correct because metoprolol is a beta-blocker that lowers heart rate; a heart rate of
48 bpm indicates bradycardia, requiring the nurse to hold the medication to prevent
hemodynamic compromise.
Q6: A client with atrial fibrillation is prescribed warfarin. The nurse understands that which
laboratory value must be monitored to evaluate the therapeutic effect of this medication?
A. Activated partial thromboplastin time (aPTT)
B. International normalized ratio (INR)
C. Prothrombin time (PT) alone
D. Platelet count
Correct Answer: B
Rationale: Correct because the INR standardizes the prothrombin time and is the required
laboratory value to monitor for therapeutic anticoagulation in clients taking warfarin.
Q7: The nurse identifies ventricular fibrillation on the cardiac monitor of an unresponsive client
with no pulse. What is the priority nursing intervention?
A. Administer amiodarone 300 mg IV push
B. Perform defibrillation immediately
C. Initiate high-quality CPR
D. Establish an IV access line
Correct Answer: B
Rationale: Priority is to immediately defibrillate the client, as ventricular fibrillation is a lethal
dysrhythmia that requires an electrical shock to terminate the chaotic rhythm.
Q8: A client with a history of heart failure is prescribed furosemide. Which statement by the
client indicates a need for further teaching regarding this medication?
A. "I will eat foods rich in potassium, like bananas and oranges."
, B. "I will weigh myself every morning before eating breakfast."
C. "I will take this medication right before going to bed."
D. "I will sit up slowly from a lying position to prevent dizziness."
Correct Answer: C
Rationale: Correct because furosemide is a loop diuretic that causes diuresis; taking it at
bedtime will disrupt sleep due to the need for frequent urination.
Q9: The nurse is assessing a client with cardiogenic shock. Which hemodynamic parameter is
most expected in this client?
A. Increased cardiac output and decreased systemic vascular resistance
B. Decreased cardiac output and increased pulmonary artery wedge pressure
C. Increased cardiac output and increased central venous pressure
D. Decreased cardiac output and decreased central venous pressure
Correct Answer: B
Rationale: Correct because cardiogenic shock results from the heart's inability to pump
effectively, leading to decreased cardiac output and backup of blood into the pulmonary system,
increasing the pulmonary artery wedge pressure.
Q10: A client presents to the emergency department with a blood pressure of 210/120 mmHg,
severe headache, and confusion. Which nursing intervention is the priority?
A. Administer a bolus of IV normal saline
B. Prepare for immediate intubation
C. Initiate a continuous IV antihypertensive infusion
D. Apply a warming blanket to prevent shivering
Correct Answer: C
Rationale: Priority is to initiate a continuous IV antihypertensive infusion to safely lower the
blood pressure in a controlled manner, as this client is experiencing a hypertensive emergency
with end-organ damage.
): Multidimensional Care III /
MDC 3 - Rasmussen
Q1: The nurse is caring for a client with heart failure who reports sudden onset of a dry,
persistent cough. Which diagnostic finding should the nurse anticipate correlating with this
symptom?
A. Brain natriuretic peptide (BNP) of 50 pg/mL
B. Chest X-ray showing pulmonary edema
C. Echocardiogram showing left ventricular hypertrophy
D. Electrocardiogram showing atrial fibrillation
Correct Answer: B
Rationale: Correct because a dry, persistent cough in heart failure is a classic sign of pulmonary
congestion, which correlates with pulmonary edema on a chest X-ray.
Q2: A client with left-sided heart failure asks why they are experiencing weight gain despite
having a poor appetite. What is the nurse's best response?
A. "Heart failure causes your body to store extra fat due to slowed metabolism."
B. "Your kidneys are retaining sodium and water, which builds up in your tissues."
C. "Poor appetite leads to decreased calorie burn, causing rapid weight gain."
D. "The medications you are taking increase your blood sugar and cause water retention."
Correct Answer: B
Rationale: Correct because decreased cardiac output in left-sided heart failure activates the
renin-angiotensin-aldosterone system, causing sodium and water retention that manifests as
weight gain.
,Q3: The nurse is reviewing the laboratory results for a client admitted with an acute myocardial
infarction (MI). Which biomarker is the most specific indicator of myocardial muscle damage?
A. Creatine kinase-MB (CK-MB)
B. High-sensitivity troponin I
C. Myoglobin
D. C-reactive protein (CRP)
Correct Answer: B
Rationale: Correct because high-sensitivity troponin I is highly specific to cardiac muscle and
rises within hours of myocardial injury, making it the gold standard for diagnosing an acute MI.
Q4: A client 2 days post-MI develops chest pain, shortness of breath, and a friction rub on
auscultation. Which complication should the nurse suspect?
A. Ventricular aneurysm
B. Cardiac tamponade
C. Pericarditis
D. Dressler syndrome
Correct Answer: C
Rationale: Correct because a pericardial friction rub accompanied by chest pain in the early
post-MI period is the hallmark sign of acute pericarditis.
Q5: The nurse is preparing to administer metoprolol to a client with hypertension. Which
assessment finding would prompt the nurse to hold the medication and contact the provider?
A. Blood pressure of 156/94 mmHg
B. Respiratory rate of 18 breaths/min
C. Heart rate of 48 bpm
D. Oxygen saturation of 95% on room air
,Correct Answer: C
Rationale: Correct because metoprolol is a beta-blocker that lowers heart rate; a heart rate of
48 bpm indicates bradycardia, requiring the nurse to hold the medication to prevent
hemodynamic compromise.
Q6: A client with atrial fibrillation is prescribed warfarin. The nurse understands that which
laboratory value must be monitored to evaluate the therapeutic effect of this medication?
A. Activated partial thromboplastin time (aPTT)
B. International normalized ratio (INR)
C. Prothrombin time (PT) alone
D. Platelet count
Correct Answer: B
Rationale: Correct because the INR standardizes the prothrombin time and is the required
laboratory value to monitor for therapeutic anticoagulation in clients taking warfarin.
Q7: The nurse identifies ventricular fibrillation on the cardiac monitor of an unresponsive client
with no pulse. What is the priority nursing intervention?
A. Administer amiodarone 300 mg IV push
B. Perform defibrillation immediately
C. Initiate high-quality CPR
D. Establish an IV access line
Correct Answer: B
Rationale: Priority is to immediately defibrillate the client, as ventricular fibrillation is a lethal
dysrhythmia that requires an electrical shock to terminate the chaotic rhythm.
Q8: A client with a history of heart failure is prescribed furosemide. Which statement by the
client indicates a need for further teaching regarding this medication?
A. "I will eat foods rich in potassium, like bananas and oranges."
, B. "I will weigh myself every morning before eating breakfast."
C. "I will take this medication right before going to bed."
D. "I will sit up slowly from a lying position to prevent dizziness."
Correct Answer: C
Rationale: Correct because furosemide is a loop diuretic that causes diuresis; taking it at
bedtime will disrupt sleep due to the need for frequent urination.
Q9: The nurse is assessing a client with cardiogenic shock. Which hemodynamic parameter is
most expected in this client?
A. Increased cardiac output and decreased systemic vascular resistance
B. Decreased cardiac output and increased pulmonary artery wedge pressure
C. Increased cardiac output and increased central venous pressure
D. Decreased cardiac output and decreased central venous pressure
Correct Answer: B
Rationale: Correct because cardiogenic shock results from the heart's inability to pump
effectively, leading to decreased cardiac output and backup of blood into the pulmonary system,
increasing the pulmonary artery wedge pressure.
Q10: A client presents to the emergency department with a blood pressure of 210/120 mmHg,
severe headache, and confusion. Which nursing intervention is the priority?
A. Administer a bolus of IV normal saline
B. Prepare for immediate intubation
C. Initiate a continuous IV antihypertensive infusion
D. Apply a warming blanket to prevent shivering
Correct Answer: C
Rationale: Priority is to initiate a continuous IV antihypertensive infusion to safely lower the
blood pressure in a controlled manner, as this client is experiencing a hypertensive emergency
with end-organ damage.
