NUR2392/NUR 2392 Exam 3 V2 |
Multidimensional Care II (MDC 2) Q&A
with Rationale | Rasmussen University
1. A client with Chronic Obstructive Pulmonary Disease (COPD) presents with a barrel chest.
The nurse understands this is primarily caused by which process?
A. Chronic inflammation of the bronchial tubes leading to mucus plugs.
B. Consistent use of accessory muscles during inspiration.
C. Alveolar destruction and air trapping within the lungs.
D. Hypertrophy of the diaphragm due to increased workload.
Correct Answer: C
Rationale: In COPD, specifically emphysema, the alveolar walls are destroyed, leading to a
loss of elastic recoil. This causes air to become trapped in the distal airspaces during
expiration, which hyperinflates the lungs. Over time, this hyperinflation increases the
anteroposterior diameter of the chest, resulting in the characteristic barrel-chest
appearance.
2. The nurse is monitoring a client receiving a heparin infusion for a deep vein thrombosis
(DVT). Which laboratory value requires immediate notification of the provider?
A. Platelet count of 90,000/mm³.
B. Hemoglobin of 13.2 g/dL.
,C. PTT of 75 seconds.
D. INR of 1.2.
Correct Answer: A
Rationale: A platelet count below 100,000/mm³ in a client receiving heparin may indicate
Heparin-Induced Thrombocytopenia (HIT). This is a serious immune-mediated reaction
that can lead to paradoxical thromboembolism and bleeding. The nurse must report this
finding immediately so that heparin can be discontinued and alternative anticoagulation
can be started.
3. A nurse is assessing a client with right-sided heart failure. Which clinical manifestation
should the nurse expect to find?
A. Peripheral edema and jugular venous distention.
B. Crackles in the lung bases.
C. Orthopnea and paroxysmal nocturnal dyspnea.
D. Pink, frothy sputum.
Correct Answer: A
Rationale: Right-sided heart failure causes blood to back up into the systemic venous
circulation rather than being effectively pumped into the lungs. This results in systemic
congestion, leading to dependent edema, hepatomegaly, and distended neck veins. Left-
sided failure, conversely, results in pulmonary congestion and respiratory symptoms like
crackles and orthopnea.
,4. Which education should the nurse provide to a client newly prescribed warfarin
(Coumadin)?
A. Avoid all foods containing Vitamin K entirely.
B. Maintain a consistent intake of green leafy vegetables.
C. Use a firm-bristled toothbrush to ensure gum health.
D. Take aspirin for minor headaches instead of acetaminophen.
Correct Answer: B
Rationale: Consistency in Vitamin K intake is crucial because Vitamin K is the antidote for
warfarin; sudden increases or decreases can fluctuate the INR levels. The client should not
avoid these foods entirely but should keep their consumption stable to allow for accurate
dosing. Additionally, the nurse should instruct the client to use a soft toothbrush and avoid
NSAIDs/aspirin due to increased bleeding risk.
5. A client presents with sharp chest pain that worsens on inspiration and is relieved by
leaning forward. The nurse suspects which condition?
A. Pericarditis.
B. Myocardial Infarction.
C. Pneumothorax.
D. Pulmonary Embolism.
Correct Answer: A
, Rationale: Pericarditis is inflammation of the pericardial sac, which often produces
pleuritic chest pain that varies with position. Leaning forward reduces the pressure of the
heart against the inflamed pericardium, providing relief. This is a classic diagnostic finding
that helps differentiate it from the pressure-like pain of a myocardial infarction.
6. The nurse is caring for a client with pneumonia. Which intervention is the priority to
improve gas exchange?
A. Administering oral antibiotics as prescribed.
B. Providing a high-protein diet for healing.
C. Performing a sputum culture and sensitivity test.
D. Encouraging the use of an incentive spirometer every hour.
Correct Answer: D
Rationale: Incentive spirometry helps promote deep breathing and lung expansion, which
prevents atelectasis and mobilizes secretions in pneumonia. Improved alveolar expansion
directly enhances gas exchange by increasing the surface area available for oxygen
diffusion. While antibiotics treat the underlying infection, they do not provide the
immediate mechanical assistance needed for gas exchange.
7. A client with atrial fibrillation is at high risk for which complication?
A. Pulmonary Stenosis.
B. Ventricular Fibrillation.
C. Cardiac Tamponade.
Multidimensional Care II (MDC 2) Q&A
with Rationale | Rasmussen University
1. A client with Chronic Obstructive Pulmonary Disease (COPD) presents with a barrel chest.
The nurse understands this is primarily caused by which process?
A. Chronic inflammation of the bronchial tubes leading to mucus plugs.
B. Consistent use of accessory muscles during inspiration.
C. Alveolar destruction and air trapping within the lungs.
D. Hypertrophy of the diaphragm due to increased workload.
Correct Answer: C
Rationale: In COPD, specifically emphysema, the alveolar walls are destroyed, leading to a
loss of elastic recoil. This causes air to become trapped in the distal airspaces during
expiration, which hyperinflates the lungs. Over time, this hyperinflation increases the
anteroposterior diameter of the chest, resulting in the characteristic barrel-chest
appearance.
2. The nurse is monitoring a client receiving a heparin infusion for a deep vein thrombosis
(DVT). Which laboratory value requires immediate notification of the provider?
A. Platelet count of 90,000/mm³.
B. Hemoglobin of 13.2 g/dL.
,C. PTT of 75 seconds.
D. INR of 1.2.
Correct Answer: A
Rationale: A platelet count below 100,000/mm³ in a client receiving heparin may indicate
Heparin-Induced Thrombocytopenia (HIT). This is a serious immune-mediated reaction
that can lead to paradoxical thromboembolism and bleeding. The nurse must report this
finding immediately so that heparin can be discontinued and alternative anticoagulation
can be started.
3. A nurse is assessing a client with right-sided heart failure. Which clinical manifestation
should the nurse expect to find?
A. Peripheral edema and jugular venous distention.
B. Crackles in the lung bases.
C. Orthopnea and paroxysmal nocturnal dyspnea.
D. Pink, frothy sputum.
Correct Answer: A
Rationale: Right-sided heart failure causes blood to back up into the systemic venous
circulation rather than being effectively pumped into the lungs. This results in systemic
congestion, leading to dependent edema, hepatomegaly, and distended neck veins. Left-
sided failure, conversely, results in pulmonary congestion and respiratory symptoms like
crackles and orthopnea.
,4. Which education should the nurse provide to a client newly prescribed warfarin
(Coumadin)?
A. Avoid all foods containing Vitamin K entirely.
B. Maintain a consistent intake of green leafy vegetables.
C. Use a firm-bristled toothbrush to ensure gum health.
D. Take aspirin for minor headaches instead of acetaminophen.
Correct Answer: B
Rationale: Consistency in Vitamin K intake is crucial because Vitamin K is the antidote for
warfarin; sudden increases or decreases can fluctuate the INR levels. The client should not
avoid these foods entirely but should keep their consumption stable to allow for accurate
dosing. Additionally, the nurse should instruct the client to use a soft toothbrush and avoid
NSAIDs/aspirin due to increased bleeding risk.
5. A client presents with sharp chest pain that worsens on inspiration and is relieved by
leaning forward. The nurse suspects which condition?
A. Pericarditis.
B. Myocardial Infarction.
C. Pneumothorax.
D. Pulmonary Embolism.
Correct Answer: A
, Rationale: Pericarditis is inflammation of the pericardial sac, which often produces
pleuritic chest pain that varies with position. Leaning forward reduces the pressure of the
heart against the inflamed pericardium, providing relief. This is a classic diagnostic finding
that helps differentiate it from the pressure-like pain of a myocardial infarction.
6. The nurse is caring for a client with pneumonia. Which intervention is the priority to
improve gas exchange?
A. Administering oral antibiotics as prescribed.
B. Providing a high-protein diet for healing.
C. Performing a sputum culture and sensitivity test.
D. Encouraging the use of an incentive spirometer every hour.
Correct Answer: D
Rationale: Incentive spirometry helps promote deep breathing and lung expansion, which
prevents atelectasis and mobilizes secretions in pneumonia. Improved alveolar expansion
directly enhances gas exchange by increasing the surface area available for oxygen
diffusion. While antibiotics treat the underlying infection, they do not provide the
immediate mechanical assistance needed for gas exchange.
7. A client with atrial fibrillation is at high risk for which complication?
A. Pulmonary Stenosis.
B. Ventricular Fibrillation.
C. Cardiac Tamponade.
