Rasmussen University NUR 2755 Exam 2 (pdf) | 2026/2027 | MDC 4
Q&A | Nursing
1. A nurse is preparing a client for surgery. The client asks, "Why do I have to
stay NPO after midnight?" Which response by the nurse is most accurate?
A) "It prevents you from having to use the bathroom during surgery."
B) "It reduces the risk of aspiration of stomach contents during anesthesia."
C) "It ensures your stomach is empty for the surgical procedure."
D) "It is a standard policy that applies to all surgical clients."
Correct Answer: "It reduces the risk of aspiration of stomach contents during
anesthesia."
Rationale: The primary reason for NPO (nothing by mouth) status before
surgery is to prevent aspiration of gastric contents during anesthesia
induction. Aspiration can lead to severe pneumonia and other complications.
Maintaining NPO status is a critical safety measure to protect the airway.
2. A client is 24 hours postoperative following abdominal surgery. The nurse
assesses the client and notes the wound edges are separating, and the client
reports a feeling of "something giving way." The nurse should suspect which
complication?
A) Infection
B) Dehiscence
C) Evisceration
D) Hematoma
Correct Answer: Dehiscence
Rationale: Dehiscence is the partial or complete separation of wound edges.
The client may report a feeling of "something giving way," and the nurse
,may observe the wound edges separating. Evisceration involves the
protrusion of internal organs through the wound, which is a more severe
complication. Prompt recognition and intervention are essential.
3. 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. Atelectasis
and pneumonia typically present with fever and cough, and wound infection
presents with localized signs.
4. 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. Clients should also be educated about the signs
and symptoms of DVT and PE.
5. 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. Prompt treatment is
essential to prevent systemic infection.
6. 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. The
PCA should not be continued or increased.
7. 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
C) Restricting oral fluids
D) Placing the client in a supine position
Correct Answer: Encouraging deep breathing and incentive spirometry
Rationale: Deep breathing and incentive spirometry help expand the lungs
and prevent atelectasis by promoting alveolar inflation and clearing
secretions. Bronchodilators may help if bronchospasm is present, but deep
breathing is the primary intervention.
8. A confused client exhibits a blood pressure of 112/84 mm Hg, a pulse rate
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
Q&A | Nursing
1. A nurse is preparing a client for surgery. The client asks, "Why do I have to
stay NPO after midnight?" Which response by the nurse is most accurate?
A) "It prevents you from having to use the bathroom during surgery."
B) "It reduces the risk of aspiration of stomach contents during anesthesia."
C) "It ensures your stomach is empty for the surgical procedure."
D) "It is a standard policy that applies to all surgical clients."
Correct Answer: "It reduces the risk of aspiration of stomach contents during
anesthesia."
Rationale: The primary reason for NPO (nothing by mouth) status before
surgery is to prevent aspiration of gastric contents during anesthesia
induction. Aspiration can lead to severe pneumonia and other complications.
Maintaining NPO status is a critical safety measure to protect the airway.
2. A client is 24 hours postoperative following abdominal surgery. The nurse
assesses the client and notes the wound edges are separating, and the client
reports a feeling of "something giving way." The nurse should suspect which
complication?
A) Infection
B) Dehiscence
C) Evisceration
D) Hematoma
Correct Answer: Dehiscence
Rationale: Dehiscence is the partial or complete separation of wound edges.
The client may report a feeling of "something giving way," and the nurse
,may observe the wound edges separating. Evisceration involves the
protrusion of internal organs through the wound, which is a more severe
complication. Prompt recognition and intervention are essential.
3. 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. Atelectasis
and pneumonia typically present with fever and cough, and wound infection
presents with localized signs.
4. 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. Clients should also be educated about the signs
and symptoms of DVT and PE.
5. 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. Prompt treatment is
essential to prevent systemic infection.
6. 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. The
PCA should not be continued or increased.
7. 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
C) Restricting oral fluids
D) Placing the client in a supine position
Correct Answer: Encouraging deep breathing and incentive spirometry
Rationale: Deep breathing and incentive spirometry help expand the lungs
and prevent atelectasis by promoting alveolar inflation and clearing
secretions. Bronchodilators may help if bronchospasm is present, but deep
breathing is the primary intervention.
8. A confused client exhibits a blood pressure of 112/84 mm Hg, a pulse rate
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
