NUR 2356 / NUR2356 Multidimensional Care I (MDC 1) CJE (Latest 2026/2027 Update) | Rasmussen University | Complete Study Guide | Verified Questions & Answers | 100% Correct Solutions | Grade A

NUR 2356 / NUR2356 Multidimensional Care I (MDC 1) CJE (Latest 2026/2027 Update) | Rasmussen University | Complete Study Guide | Verified Questions & Answers | 100% Correct Solutions | Grade A Q: The nurse is caring for four clients. Which client should the nurse first? Chest pain and sudden dyspnea (shortness of breath) are priority (possible Pulmonary Embolism/ myocardial infarction aka heart attack) this is an immediate threat to life. Q: The nurse prepares to enter the room of a client with C. difficle diarrhea. What PPE is required? Gloves and gown. (Mask are not routinely required unless the risk of splash.) Q: The nurse is teaching an UAP/unlicensed assistive personnel about precautions. Which statement shows understanding. Standard precautions require gloves whenever contact with blood/ bloody fluids may occur. Q: The nurse is starting an IV on a client. After palpating the vein, what should the nurse do next? Hand hygiene and clean gloves are required before inserting the IV. Q: The nurse cares for a client on airborne precautions for tuberculosis. Which action is most important? Negative-pressure room with N95 use is critical for TB; door closed and mask for transport also, but room type is key. Q: The nurse is reinforcing teaching about fire safety. Which action comes first if a fire is discovered in a client’s room? RACE: Rescue, Alarm, Contain, Extinguish. Q: The nurse notes that the side rails are all up on a confused client’s bed. What is the best action? All rails up can be considered a restraint; reduce to the least restrictive while maintaining safety. Q: Which task can the nurse delegate to a UAP? Standardized tasks such as finger-stick glucose and report results; RN handles teaching, assessment, evaluation. Q: The nurse receives report on four clients. Which client should be assessed first using ABCs? Respiratory distress with increased work of breathing is top priority. Q: The nurse prepares to administer medications through a PEG tube. What is the priority action? Placement must be verified before instilling anything to prevent aspiration. Q: A client with pneumonia has the following data: RR 26, SpO₂ 89% on room air, temp 101.5°F, productive cough. What is the priority nursing action? Low O₂ saturation makes oxygen administration the immediate priority. Q: Which of the following findings in a client with heart failure requires the most immediate intervention? Acute confusion suggests decreased cerebral perfusion/hypoxia—priority. Q: A COPD client’s baseline SpO₂ is 90–92% on 2 L. Today it is 88% on 2 L with no distress. What should the nurse do? Reassess and position first; mild drop with no distress requires further assessment, not emergency escalation. Q: A client with a DVT suddenly complains of sharp chest pain and shortness of breath. What is the priority action? Suspected pulmonary embolism → position and oxygen first, then notify provider. Q: The nurse hears wheezing in a client with asthma. Which medication does the nurse expect to give first? Short-acting bronchodilator is the rescue medication for acute wheezing. Q: A post-op client is receiving 2 L O₂ via nasal cannula and reports incisional pain 8/10. SpO₂ 94%, RR 18. What action is best? Give prescribed opioid as ordered Q: The nurse identifies which finding as an early sign of hypoxia? Restlessness and anxiety Q: Which position is best to improve oxygenation in a client with shortness of breath? High Fowler's maximizes lung expansion. Q: The nurse notes an irregular heartbeat and new onset dizziness in a client. What is the priority assessment? Obtain vital signs and apical pulse Q: A client reports chest pain. Which question should the nurse ask first? "Where is the pain and does it radiate?" Q: Which finding in a client with IV normal saline at 150 mL/hr is most concerning? New crackles in lung bases (Crackles may indicate fluid overload from high IV rate.) Q: A client with vomiting and diarrhea has BP 88/54, HR 120, dry mucous membranes, and poor skin turgor. Which IV order is most appropriate? 0.9% NS bolus (Hypovolemia → isotonic fluid bolus.) A client’s potassium is 2.9 mEq/L. Which assessment is priority? Heart rhythm (Hypokalemia can cause dysrhythmias; monitor heart rhythm.) Which food should the nurse recommend for a client with low potassium? Bananas are high in potassium. A client with heart failure is on furosemide. Which lab value is most concerning? Potassium 3.0 (Loop diuretics can cause hypokalemia.) The nurse suspects fluid overload. Which finding supports this? Bounding pulse and weight gain occur with excess fluid. A client with diabetes is diaphoretic, shaky, and confused. What is the priority action? Check blood glucose Signs of hypoglycemia → check glucose immediately. The nurse cares for a client with blood glucose 42 mg/dL who is awake and able to swallow. What is the best action? Give 4 oz juice Conscious and able to swallow → give fast-acting carbs. A client with type 2 diabetes reports numbness in both feet. Which intervention is most important? Teach daily foot inspection (Peripheral neuropathy → risk for injury; daily foot checks are critical.) The nurse reviews labs for a client: Na 128, K 4.0, BUN 16. Which is priority? Restrict fluids (Hyponatremia often treated with fluid restriction unless otherwise ordered.) The nurse cares for an older adult on bedrest. What intervention is most important to prevent DVT? Encourage ankle pumps and leg exercises (Leg exercises promote venous return and reduce DVT risk.) The nurse turns a bedridden client every 2 hours. What is the primary reason for this intervention? Repositioning prevents pressure injuries. A client with a hip fracture is ordered to be non–weight-bearing. Which action requires intervention? Client uses walker and puts toe on the floor for balance (Non-weight-bearing means no weight on the extremity; even toe-touch should be clarified.) The nurse notes redness over a client’s sacrum that does not blanch. What stage pressure injury is this? Non-blanchable erythema of intact skin = Stage 1. Which order helps prevent contractures in a client after stroke with hemiparesis? Hand rolls and ROM prevent contractures. A client using a cane should be taught to... Move the cane and weaker leg together Which client is at greatest risk for pressure injury? Incontinence, immobility, age, and confusion increase risk. The nurse teaches a client with osteoporosis about home safety. Which statement shows need for more teaching? "I will climb on a chair to reach high shelves." A post-op client refuses to use the incentive spirometer because it hurts. What is the best response? "I'll premedicate you for pain and help you use it." (Treat pain and assist with use; it's important to prevent complications.) A client reports calf pain when walking that stops with rest. What is this finding most consistent with? Peripheral arterial disease (Intermittent claudication (pain with walking relieved by rest) is typical of PAD.) A post-op client has not voided in 8 hours. Bladder scan shows 650 mL. What is the priority action? Straight-catheterize per protocol The nurse is caring for a client with a Foley catheter. Which action prevents infection? Maintain closed system and keep bag below bladder Which assessment is most important before giving furosemide? Blood pressure and potassium level (Loop diuretics can lower BP and K⁺; assess these before administration.) A client with constipation is prescribed stool softener and increased fiber. Which food is best? Fresh fruits and vegetables A client with diarrhea is at risk for what electrolyte imbalance? Hypokalemia (Potassium is lost through GI tract with diarrhea.) The nurse notes dark, tarry stools in a client. What is the term for this? Melena = black tarry stools from upper GI bleeding. A client taking opioids after surgery reports no bowel movement for 3 days. What is the best action? Encourage walking and fluids The nurse is administering enteral feeding via NG tube. Which finding requires intervention? Client is lying flat during feeding Which nursing diagnosis is highest priority for a client with severe diarrhea? Deficient fluid volume (fluid deficit is most life threatening.) The nurse notes a client’s urine output is 200 mL over 8 hours. What is the priority action? Notify provider of low urine output (Urine output 30 mL/hr indicates possible renal perfusion issues; report.) A client reports pain 9/10 and is grimacing. Vitals are stable. The nurse’s first action is to: Give pain medication as prescribed. The nurse is teaching about the use of a PCA pump. Which statement requires further teaching? "My family can push the button for me when I'm asleep." Only the patient should push the PCA button. A confused client tries to pull out IV lines. What is the best initial intervention? Move client closer to nurse's station and reorient The nurse cares for a client experiencing anxiety before surgery. What is the best response? "Tell me more about what is worrying you." Which finding suggests possible delirium in an older adult? Sudden confusion and disorganized thinking after surgery. (Delirium is acute and often after illness or surgery.) A client with depression states, “Nothing will ever get better.” What is the nurse’s priority? Ask directly if the client has thoughts of self-harm. The nurse is teaching an older adult about new antihypertensive medication. What approach is best? Use large print handouts and simple language When using the teach-back method, the nurse should... Ask the client to repeat the instructions in their own words A client who speaks limited English is scheduled for surgery. Who should provide informed consent teaching? Professional medical interpreter The nurse suspects a client may be a victim of abuse. What is the priority action? Interview the client alone in a private setting Which client medication requires double-check by another nurse? Heparin IV infusion Before giving digoxin, which assessment is priority? Apical pulse for 1 full minute The nurse calculates the correct dose but gets a value much larger than usual. What is the best action? Recalculate and verify with pharmacy or provider Which statement shows the client understands nitroglycerin sublingual use? "If pain is not relieved after one tablet, I can take up to 3, 5 minutes apart." The nurse gives the wrong dose of medication. What is the priority action? Monitor the client and notify provider A client allergic to penicillin is prescribed ampicillin. What should the nurse do? Hold the medication and notify provider Which route has the fastest systemic absorption? Intravenous The nurse prepares to administer insulin lispro. When should the nurse give it in relation to meals? Immediately before or with meals The nurse is giving ear drops to an adult. How should the ear be positioned? Pull pinna up and back After giving an IM injection in the deltoid, the nurse documents the site as... Deltoid muscle, upper arm The nurse has four tasks. Which should be done first? Assess a new post-op client just arriving from PACU The nurse notes a potassium level of 6.2 mEq/L on a client. What is the priority action? Place on a cardiac monitor Which client should the nurse see first at the start of shift? Client with new onset slurred speech The nurse receives report. Which task is appropriate to assign to LPN? Monitoring a stable client with chronic COPD. (LPN can monitor stable clients; RN handles initial assessment and teaching.) The nurse finds a client with a chest tube whose collection chamber is tipped over. What is the first action? Place chamber upright and assess for air leak. (Re-establish system and assess; do not clamp/remove without order.) The UAP reports a client’s BP is 80/50. What should the nurse do first? Recheck BP manually and assess client. (Verify abnormal reading and assess condition immediately.) A client with sepsis has orders for blood cultures and IV antibiotics. What should the nurse do first? Draw blood cultures. (Culture must be taken prior to starting antibiotics.) The nurse cares for four clients. Which tasks can be delegated to UAP? -Assisting a stable client with a bath -Measuring intake and output -Reporting changes in vital signs The nurse notes that a client’s O₂ tubing is kinked and SpO₂ is 85%. What is the first action? Fix the kink and reassess SpO₂ A client on opioids has RR 8 and difficult to arouse. What is the priority action? Administer naloxone per standing order. (Respiratory depression from opioids → naloxone immediately, then notify provider.) The nurse assesses four clients. Which finding is most concerning? Client with new unilateral weaknes A client with HF gains 5 lb in 3 days and has 2+ edema. What is the priority instruction? Restrict fluids and sodium as ordered A client receiving blood transfusion develops itching and hives. What is the priority action? Stop the transfusion and maintain IV with normal saline. The nurse teaches a client with HF about daily weights. Which statement shows correct understanding? "I'll weigh each morning after I urinate, using the same scale." A client with pneumonia is using an incentive spirometer incorrectly. What should the nurse instruct? "Inhale slowly and deeply through the mouthpiece, then hold your breath." The client with COPD is on 2 L O₂ and has thick secretions. What nursing action is most helpful? Encourage increased fluid intake, if not contraindicated. A client admitted with dehydration now has clear lungs, BP 110/70, and good urine output. What is the best evaluation statement? "Client's fluid balance has improved." The nurse assesses a post-op client 6 hours after surgery. Which finding is most concerning? Saturated dressing with bright red blood A client with a new colostomy is tearful and refusing to look at the stoma. What is the best nursing response? "Tell me how you're feeling about your colostomy." The nurse prepares to discharge a client with HF. Which statement shows need for more teaching? "If I feel short of breath when lying flat, I will just use extra pillows and not worry." (Orthopnea is a sign of worsening HF; should notify provider.) Which client should the charge nurse assign to a new graduate RN? Stable post-op client on day 2 requiring routine care. The nurse is reinforcing teaching on infection prevention for a client with a PICC line at home. Which statement is correct? "I will wash my hands before touching the dressing." The nurse notes that a confused client keeps trying to get out of bed. Which intervention is best for fall prevention? Use a bed alarm and keep call light within reach The nurse is reviewing lab results. Which requires immediate follow-up? Hemoglobin 8 g/dL (Low hemoglobin indicates anemia and decreased oxygen-carrying capacity.) A client states, “I don’t want CPR or to be put on a breathing machine.” What should the nurse do first? Ask if the client would like to speak with provider about an advance directive/DNR. A family member says, “Why are you letting my father walk when he is so weak?” What is the best response? "Walking helps prevent complications like blood clots. I'll stay with him for safety." A client after surgery reports feeling “something popping” at the incision, and the nurse sees organs protruding. What is the priority action? Cover with sterile saline-moistened dressing and notify provider A client with HF asks, “Why do I need to limit salt?” "Salt makes your body hold onto fluid, which worsens heart failure." (Sodium increases fluid retention and worsens HF symptoms.) A client on contact precautions wants to walk in the hall. What should the nurse do? Allow walking with gown and gloves worn by client. (Client must follow precautions if leaving room; visitors/staff also wear appropriate PPE.) A student nurse asks how to prioritize care. Best explanation? "Use ABCs, Maslow, and safety to decide who needs you first." Clinical Judgment Framework • Steps: • Recognize cues (what is abnormal?) • Analyze cues (what do these findings mean together?) • Prioritize hypotheses (what is most likely/most dangerous?) • Generate solutions (what interventions are appropriate?) • Take action (what will I do first?) • Evaluate outcomes (did it work? what next?) • Always combine: • ABCs (Airway, Breathing, Circulation) • Maslow (physiological, safety first) • Nursing process (Assess → Plan → Implement → Evaluate) Vital Signs & “Danger Numbers” • Temp: 101°F with other infection signs • HR: 60 or 120 • RR: 12 or 24 • SBP: 90 or drop 30 from baseline • SpO₂: 92% (or lower than baseline if COPD) • Urine output: 30 mL/hr (Oxygenation & Gas Exchange) • Recognize early hypoxia: • Restlessness, anxiety, tachycardia, tachypnea • Late signs: • Cyanosis, confusion, low BP, low SpO₂ • Interventions: • Position high Fowler's • Apply O₂ per order (usually start 2 L NC) • Encourage C&DB, IS, ambulation • Reassess respirations and SpO₂ (Perfusion / Cardiac) • Red-flag symptoms: • Chest pain, SOB, diaphoresis, radiating pain • New confusion or weakness • Irregular rhythm + dizziness • Heart failure cues: • Weight gain, edema, crackles, orthopnea • Interventions: • Daily weights • Monitor I&O, restrict fluids/Na as ordered • Elevate HOB, oxygen as needed (Fluid & Electrolytes) • Hypovolemia: • Dry mucous membranes, poor turgor, low BP, high HR, low urine • Hypervolemia: • Edema, crackles, weight gain, bounding pulse • Potassium: • Low K⁺ → cramps, weak pulse, dysrhythmias • High K⁺ → peaked T waves, dysrhythmias • Typical IVs: • Isotonic: 0.9% NS, LR (for volume) • Hypotonic: 0.45% NS (cell hydration; use cautiously) • Hypertonic: 3% NS (brain swelling; closely monitored) (Infection Control & Safety) • Standard Precautions: • Gloves for any body fluids, hand hygiene always • Contact: gown + gloves (C. diff, MRSA, draining wounds) • Droplet: mask (flu, meningitis) • Airborne: N95 + negative-pressure room (TB, measles) • Safety: • Fall prevention, bed in low position, call light, non-skid socks • Use least restrictive alternative before restraints E. Mobility, Skin & Musculoskeletal • Pressure injury prevention: • Turn q2h, float heels, moisture control, nutritional support • DVT prevention: • ROM, SCDs, ambulation, adequate fluids • Hip fracture/post-op: • Maintain alignment (abductor pillow), follow weight-bearing orders (Elimination (GI/GU) • Constipation: • Fiber, fluids, activity, stool softeners • Diarrhea: • Risk for fluid deficit and hypokalemia • Urinary retention: • Assess bladder, scan, straight cath per order Basic Pharmacology • 5+ Rights: right client, drug, dose, route, time, documentation, reason • High-alert meds (independent double-check): insulin, heparin, some IV drips • Digoxin: • Check apical HR 1 min; hold 60 • Furosemide: • Check BP, K⁺, I&O, weight • Insulin: • Rapid (lispro/aspart): give with meals • Hypoglycemia: shaky, sweaty, confused → check BG, give 15 g carb (Delegation & Roles) • RN: initial assessment, teaching, evaluation, unstable/critical clients • LPN: stable clients with predictable outcomes, some meds, wound care • UAP: ADLs, vitals, I&O, ambulation, positioning, reporting changes Test-Taking Strategy for CJE 1. Read the stem: What’s the real question? Priority? Safety? First action? 2. Identify critical cues (vitals, changes, red-flag symptoms). 3. Decide: Is this an assessment question or an intervention question? 4. Apply ABCs + safety first. 5. Eliminate answers that: • Are outside scope of practice • Delay necessary care • Are focused on the nurse’s needs, not the patient High-Yield Cue Cheat Sheet (“If You See This → Do This”) Airway & Breathing Cues • Stridor, no breath sounds, severe wheeze, choking → Call rapid response, prepare for airway support. • RR 30, use of accessory muscles, tripod position → Sit up, apply O₂, assess lungs, notify provider. • SpO₂ 90% (or drop below COPD baseline) → Check probe, position, apply O₂, reassess, then notify. Circulation & Perfusion Cues • Chest pain + SOB + diaphoresis → ABCs, O₂, vitals, ECG, notify provider; treat like MI until ruled out. • New confusion, restlessness, or agitation → Think: hypoxia, low perfusion, low glucose. Check VS + glucose. • BP 90 systolic, MAP 65, weak pulses → Suspect shock/hypovolemia → assess, notify, prepare fluids. • Sudden unilateral weakness or slurred speech → Suspected stroke → rapid response, CT, time-critical. Fluid & Electrolytes • Rapid weight gain (2-3 lb/day or 5 lb in a week) → Fluid overload → daily weights, restrict fluids/Na, notify provider. • K⁺ 5.0 mEq/L or 3.5 mEq/L → Put on heart monitor, anticipate IV meds to correct, notify provider. • Crackles + edema + SOB → HF or overload → sit up, O₂, possibly diuretics per orders. Infection & Sepsis • Temp 101°F + HR 90 + RR 20 + suspected infection → Suspect sepsis → notify provider, expect cultures, IV fluids, antibiotics. • Red, warm IV site with pain or streaking → Stop infusion, remove IV, notify provider, new site. Neuro Cues • Sudden change in LOC, pupil changes, new confusion → Neuro emergency → assess ABCs, check glucose, notify provider/rapid. • Post-op client who is very difficult to arouse + low RR → Possible opioid/sedation problem → naloxone, O₂, support airway. Respiratory & Post-Op Complications • Post-op client with sudden chest pain and dyspnea → Possible PE → ABCs, O₂, high Fowler's, notify provider. • Abdominal surgery + "popping" + organs visible (evisceration) → Cover with sterile, warm saline-moistened gauze, low Fowler's with knees bent, call provider. Safety & Delegation • Anything requiring assessment, teaching, or evaluation → RN only. • Unstable client or new admission → RN, not LPN/UAP. • UAP reports abnormal VS → RN must reassess and decide action. Diabetes/Glucose • Shaky, sweaty, pale, confused diabetic → Check BG; if low and conscious → give fast carb; if unconscious → emergency (IV dextrose/glucagon per protocol).