NUR2356 Multidimensional Care I / MDC
1 – Book 3 Exam And Answers Plus
Rationales Rasmussen University
Question 1
A client is admitted with severe muscle weakness, hyporeflexia, and an
electrocardiogram (ECG) demonstrating flattened T waves and
prominent U waves. Which electrolyte imbalance is present?
A) Hyperkalemia
B) Hyponatremia
C) Hypokalemia
D) Hypercalcemia
╔════════════════════╗
✅ Correct Answer: C
╚════════════════════╝
Rationale: Hypokalemia (low potassium) presents with muscle weakness,
hyporeflexia, flattened T waves, and prominent U waves on ECG. These
classic ECG changes are hallmark signs of potassium depletion.
Question 2
A client's arterial blood gas (ABG) results show: pH 7.28, PaCO₂ 54
mmHg, and HCO₃⁻ 25 mEq/L. How should the nurse interpret these
findings?
,A) Metabolic acidosis
B) Metabolic alkalosis
C) Respiratory acidosis
D) Respiratory alkalosis
╔════════════════════╗
✅ Correct Answer: C
╚════════════════════╝
Rationale: A pH below 7.35 indicates acidosis. The PaCO₂ is elevated
above 45 mmHg, demonstrating that the respiratory system is retaining
carbon dioxide (an acid). Because the bicarbonate level (HCO₃⁻) is within
the normal reference range of 22–26 mEq/L, this is an uncompensated
respiratory acidosis.
Question 3
A nurse is planning care for a client who is scheduled for elective
surgery. Which of the following details represents the nurse's legal
responsibility regarding informed consent?
A) Explaining the specific risks and benefits of the surgery
B) Witnessing the client's signature on the consent form
C) Obtaining the client's signature on the consent form
D) Determining the client's capacity to consent
╔════════════════════╗
✅ Correct Answer: B
╚════════════════════╝
Rationale: The nurse's legal responsibility regarding informed consent is
to witness the client's signature, ensure the client is signing voluntarily,
and confirm that the client appears to understand the information. The
physician is responsible for explaining risks, benefits, and alternatives.
,Question 4
A patient with a history of COPD is admitted for an acute exacerbation.
He lives alone and expresses fear that he will lose his independence. His
SpO₂ is 89% on 2L nasal cannula, and he appears anxious, using
accessory muscles to breathe. Which multidimensional nursing
intervention is the priority to address both his physiological stability and
his psychosocial distress?
A) Increase oxygen flow to 6L via simple mask to alleviate anxiety
B) Assist the patient with pursed-lip breathing while remaining at the
bedside
C) Administer a PRN dose of alprazolam to treat the patient's fear
D) Request a social work consult to discuss long-term care facilities
immediately
╔════════════════════╗
✅ Correct Answer: B
╚════════════════════╝
Rationale: Pursed-lip breathing improves gas exchange by keeping
airways open longer (physiological) and provides the patient with a
sense of control over his dyspnea, which directly mitigates anxiety.
Remaining at the bedside addresses his psychosocial distress while the
breathing technique addresses his physiological instability.
Question 5
If a surgical wound was closed with sutures, what is the healing process
called?
A) Secondary intention
B) Tertiary intention
C) Primary intention
D) Delayed primary closure
╔════════════════════╗
✅ Correct Answer: C
, ╚════════════════════╝
Rationale: Primary intention healing occurs when wound edges are
approximated and closed with sutures, staples, or adhesive. This results
in minimal scarring and faster healing. Secondary intention involves
wounds left open to heal from the bottom up, and tertiary intention
involves delayed closure.
Question 6
What is the medical term to describe thick, yellow drainage from a
wound?
A) Serous
B) Sanguineous
C) Purulent
D) Serosanguineous
╔════════════════════╗
✅ Correct Answer: C
╚════════════════════╝
Rationale: Purulent drainage is thick, yellow, green, or brown and
indicates infection. Serous drainage is clear and watery; sanguineous is
bloody; serosanguineous is pink and watery (blood-tinged serous).
Question 7
Which of the following is the correct management of cellulitis?
A) Use a tight bandage on the affected area
B) Do not apply heat to the affected area
C) Use a warm, moist towel on the affected area
D) Use a cold, dry towel on the affected area
1 – Book 3 Exam And Answers Plus
Rationales Rasmussen University
Question 1
A client is admitted with severe muscle weakness, hyporeflexia, and an
electrocardiogram (ECG) demonstrating flattened T waves and
prominent U waves. Which electrolyte imbalance is present?
A) Hyperkalemia
B) Hyponatremia
C) Hypokalemia
D) Hypercalcemia
╔════════════════════╗
✅ Correct Answer: C
╚════════════════════╝
Rationale: Hypokalemia (low potassium) presents with muscle weakness,
hyporeflexia, flattened T waves, and prominent U waves on ECG. These
classic ECG changes are hallmark signs of potassium depletion.
Question 2
A client's arterial blood gas (ABG) results show: pH 7.28, PaCO₂ 54
mmHg, and HCO₃⁻ 25 mEq/L. How should the nurse interpret these
findings?
,A) Metabolic acidosis
B) Metabolic alkalosis
C) Respiratory acidosis
D) Respiratory alkalosis
╔════════════════════╗
✅ Correct Answer: C
╚════════════════════╝
Rationale: A pH below 7.35 indicates acidosis. The PaCO₂ is elevated
above 45 mmHg, demonstrating that the respiratory system is retaining
carbon dioxide (an acid). Because the bicarbonate level (HCO₃⁻) is within
the normal reference range of 22–26 mEq/L, this is an uncompensated
respiratory acidosis.
Question 3
A nurse is planning care for a client who is scheduled for elective
surgery. Which of the following details represents the nurse's legal
responsibility regarding informed consent?
A) Explaining the specific risks and benefits of the surgery
B) Witnessing the client's signature on the consent form
C) Obtaining the client's signature on the consent form
D) Determining the client's capacity to consent
╔════════════════════╗
✅ Correct Answer: B
╚════════════════════╝
Rationale: The nurse's legal responsibility regarding informed consent is
to witness the client's signature, ensure the client is signing voluntarily,
and confirm that the client appears to understand the information. The
physician is responsible for explaining risks, benefits, and alternatives.
,Question 4
A patient with a history of COPD is admitted for an acute exacerbation.
He lives alone and expresses fear that he will lose his independence. His
SpO₂ is 89% on 2L nasal cannula, and he appears anxious, using
accessory muscles to breathe. Which multidimensional nursing
intervention is the priority to address both his physiological stability and
his psychosocial distress?
A) Increase oxygen flow to 6L via simple mask to alleviate anxiety
B) Assist the patient with pursed-lip breathing while remaining at the
bedside
C) Administer a PRN dose of alprazolam to treat the patient's fear
D) Request a social work consult to discuss long-term care facilities
immediately
╔════════════════════╗
✅ Correct Answer: B
╚════════════════════╝
Rationale: Pursed-lip breathing improves gas exchange by keeping
airways open longer (physiological) and provides the patient with a
sense of control over his dyspnea, which directly mitigates anxiety.
Remaining at the bedside addresses his psychosocial distress while the
breathing technique addresses his physiological instability.
Question 5
If a surgical wound was closed with sutures, what is the healing process
called?
A) Secondary intention
B) Tertiary intention
C) Primary intention
D) Delayed primary closure
╔════════════════════╗
✅ Correct Answer: C
, ╚════════════════════╝
Rationale: Primary intention healing occurs when wound edges are
approximated and closed with sutures, staples, or adhesive. This results
in minimal scarring and faster healing. Secondary intention involves
wounds left open to heal from the bottom up, and tertiary intention
involves delayed closure.
Question 6
What is the medical term to describe thick, yellow drainage from a
wound?
A) Serous
B) Sanguineous
C) Purulent
D) Serosanguineous
╔════════════════════╗
✅ Correct Answer: C
╚════════════════════╝
Rationale: Purulent drainage is thick, yellow, green, or brown and
indicates infection. Serous drainage is clear and watery; sanguineous is
bloody; serosanguineous is pink and watery (blood-tinged serous).
Question 7
Which of the following is the correct management of cellulitis?
A) Use a tight bandage on the affected area
B) Do not apply heat to the affected area
C) Use a warm, moist towel on the affected area
D) Use a cold, dry towel on the affected area
