Rasmussen University NUR 2755 Final Exam (pdf) | 2026/2027 | MDC
4 Q&A | Nursing
1. A nurse is caring for a client with increased intracranial pressure (ICP).
Which nursing intervention is the priority?
A) Encouraging frequent coughing and deep breathing
B) Elevating the head of the bed to 30 degrees
C) Administering hypotonic IV fluids
D) Maintaining a quiet environment with minimal stimulation
Correct Answer: Elevating the head of the bed to 30 degrees
Rationale: Elevating the head of the bed to 30 degrees promotes venous
drainage from the head and helps reduce ICP. While maintaining a quiet
environment is important, it is not the primary intervention. Coughing and
hypotonic fluids can increase ICP.
2. A nurse is monitoring a client who had a thyroidectomy. Which assessment
finding requires immediate intervention?
A) Hoarseness
B) Sore throat
C) Laryngeal stridor
D) Difficulty swallowing
Correct Answer: Laryngeal stridor
Rationale: Laryngeal stridor indicates airway obstruction and is a medical
emergency following thyroidectomy. Hoarseness, sore throat, and difficulty
swallowing are expected postoperative findings.
,3. A client with cirrhosis is at risk for hepatic encephalopathy. Which dietary
modification should the nurse implement?
A) Increase protein intake
B) Limit carbohydrates
C) Decrease protein intake
D) Encourage high-sodium foods
Correct Answer: Decrease protein intake
Rationale: Protein breakdown leads to ammonia accumulation, which
worsens hepatic encephalopathy. A low-protein diet is often recommended to
reduce ammonia levels. Sodium should be restricted, not encouraged, in
cirrhosis.
4. Which laboratory value should the nurse monitor closely for a client
receiving furosemide?
A) Serum creatinine
B) Serum potassium
C) White blood cell count
D) Hemoglobin
Correct Answer: Serum potassium
Rationale: Furosemide is a loop diuretic that can cause significant potassium
loss, leading to hypokalemia. Potassium levels should be monitored closely.
Creatinine and hemoglobin are not the primary concerns with furosemide.
5. What is the priority nursing action for a client with a new tracheostomy
and copious secretions?
,A) Suction the tracheostomy tube
B) Increase oral fluid intake
C) Elevate the head of the bed
D) Notify the provider
Correct Answer: Suction the tracheostomy tube
Rationale: Airway clearance is the priority. Suctioning is the immediate
response to copious secretions to maintain a patent airway. Elevating the
head of the bed and notifying the provider are secondary actions.
6. A client with neutropenia requires which nursing intervention?
A) Insert a Foley catheter
B) Limit visitors and ensure hand hygiene
C) Administer a live virus vaccine
D) Encourage raw fruits and vegetables
Correct Answer: Limit visitors and ensure hand hygiene
Rationale: Infection prevention is critical for neutropenic clients due to
immunosuppression. Limiting visitors, ensuring hand hygiene, and avoiding
raw foods and live vaccines are essential interventions.
7. Which ABG result is expected in a client with prolonged vomiting?
A) pH 7.31, PaCO2 50, HCO3 28
B) pH 7.48, PaCO2 44, HCO3 30
C) pH 7.22, PaCO2 30, HCO3 15
D) pH 7.38, PaCO2 38, HCO3 24
, Correct Answer: pH 7.48, PaCO2 44, HCO3 30
Rationale: Prolonged vomiting leads to loss of hydrochloric acid (HCl),
causing metabolic alkalosis. This is characterized by an elevated pH (>7.45),
elevated HCO3 (>26), and compensatory elevation in PaCO2.
8. A client is diagnosed with a pulmonary embolism. Which assessment
finding is most consistent with this condition?
A) Bradycardia and hypotension
B) Dyspnea, pleuritic chest pain, and tachycardia
C) Fever and productive cough
D) Wheezing and prolonged expiration
Correct Answer: Dyspnea, pleuritic chest pain, and tachycardia
Rationale: A pulmonary embolism (PE) typically presents with sudden
dyspnea, pleuritic chest pain (sharp on inspiration), and tachycardia. A
feeling of impending doom may also be present.
9. A client with a flail chest is experiencing paradoxical chest movement. The
nurse should prioritize which intervention?
A) Administering pain medication
B) Applying a chest binder
C) Ensuring adequate oxygenation and ventilation
D) Placing the client in a supine position
Correct Answer: Ensuring adequate oxygenation and ventilation
4 Q&A | Nursing
1. A nurse is caring for a client with increased intracranial pressure (ICP).
Which nursing intervention is the priority?
A) Encouraging frequent coughing and deep breathing
B) Elevating the head of the bed to 30 degrees
C) Administering hypotonic IV fluids
D) Maintaining a quiet environment with minimal stimulation
Correct Answer: Elevating the head of the bed to 30 degrees
Rationale: Elevating the head of the bed to 30 degrees promotes venous
drainage from the head and helps reduce ICP. While maintaining a quiet
environment is important, it is not the primary intervention. Coughing and
hypotonic fluids can increase ICP.
2. A nurse is monitoring a client who had a thyroidectomy. Which assessment
finding requires immediate intervention?
A) Hoarseness
B) Sore throat
C) Laryngeal stridor
D) Difficulty swallowing
Correct Answer: Laryngeal stridor
Rationale: Laryngeal stridor indicates airway obstruction and is a medical
emergency following thyroidectomy. Hoarseness, sore throat, and difficulty
swallowing are expected postoperative findings.
,3. A client with cirrhosis is at risk for hepatic encephalopathy. Which dietary
modification should the nurse implement?
A) Increase protein intake
B) Limit carbohydrates
C) Decrease protein intake
D) Encourage high-sodium foods
Correct Answer: Decrease protein intake
Rationale: Protein breakdown leads to ammonia accumulation, which
worsens hepatic encephalopathy. A low-protein diet is often recommended to
reduce ammonia levels. Sodium should be restricted, not encouraged, in
cirrhosis.
4. Which laboratory value should the nurse monitor closely for a client
receiving furosemide?
A) Serum creatinine
B) Serum potassium
C) White blood cell count
D) Hemoglobin
Correct Answer: Serum potassium
Rationale: Furosemide is a loop diuretic that can cause significant potassium
loss, leading to hypokalemia. Potassium levels should be monitored closely.
Creatinine and hemoglobin are not the primary concerns with furosemide.
5. What is the priority nursing action for a client with a new tracheostomy
and copious secretions?
,A) Suction the tracheostomy tube
B) Increase oral fluid intake
C) Elevate the head of the bed
D) Notify the provider
Correct Answer: Suction the tracheostomy tube
Rationale: Airway clearance is the priority. Suctioning is the immediate
response to copious secretions to maintain a patent airway. Elevating the
head of the bed and notifying the provider are secondary actions.
6. A client with neutropenia requires which nursing intervention?
A) Insert a Foley catheter
B) Limit visitors and ensure hand hygiene
C) Administer a live virus vaccine
D) Encourage raw fruits and vegetables
Correct Answer: Limit visitors and ensure hand hygiene
Rationale: Infection prevention is critical for neutropenic clients due to
immunosuppression. Limiting visitors, ensuring hand hygiene, and avoiding
raw foods and live vaccines are essential interventions.
7. Which ABG result is expected in a client with prolonged vomiting?
A) pH 7.31, PaCO2 50, HCO3 28
B) pH 7.48, PaCO2 44, HCO3 30
C) pH 7.22, PaCO2 30, HCO3 15
D) pH 7.38, PaCO2 38, HCO3 24
, Correct Answer: pH 7.48, PaCO2 44, HCO3 30
Rationale: Prolonged vomiting leads to loss of hydrochloric acid (HCl),
causing metabolic alkalosis. This is characterized by an elevated pH (>7.45),
elevated HCO3 (>26), and compensatory elevation in PaCO2.
8. A client is diagnosed with a pulmonary embolism. Which assessment
finding is most consistent with this condition?
A) Bradycardia and hypotension
B) Dyspnea, pleuritic chest pain, and tachycardia
C) Fever and productive cough
D) Wheezing and prolonged expiration
Correct Answer: Dyspnea, pleuritic chest pain, and tachycardia
Rationale: A pulmonary embolism (PE) typically presents with sudden
dyspnea, pleuritic chest pain (sharp on inspiration), and tachycardia. A
feeling of impending doom may also be present.
9. A client with a flail chest is experiencing paradoxical chest movement. The
nurse should prioritize which intervention?
A) Administering pain medication
B) Applying a chest binder
C) Ensuring adequate oxygenation and ventilation
D) Placing the client in a supine position
Correct Answer: Ensuring adequate oxygenation and ventilation
