MDC4 Practice Questions with 100% Correct
Answers
The client recovering from a head injury is arousable and participating in care. Which
of the following demonstrates effective client teaching in preventing intracranial
pressure?
Maintain an elevated head of the bed to 30 degrees
The spouse of a 67-year-old male patient with early-stage Alzheimer's disease (AD) tells
the nurse, "I am exhausted from worrying all the time. I do not know what to do."
Which actions are best for the nurse to take next (select all that apply)?
Offer ideas for ways to distract or redirect the patient.
Teach the spouse about adult day care as a possible respite.
Ask the spouse what she knows and has considered about dementia care options.
The high-pressure alarm sounds on a ventilator. AfterAfter looking over the client and
the ventilator, the nurse takes what action next?
Suctions the client to remove excess excretions
The client has returned to the surgical unit from the post-anesthesia unit. The client's
respirations are rapid and shallow, the pulse is 120 beats/min, and the blood pressure is
88/52 the client's LOC is declining. what should the nurse do first?
Call the rapid response team/ Medical emergency team
The nurse has instructed the family of a client who has had a stroke and has
homonymous hemianopsia about measures to help the client overcome the deficit. the
nurse determines the understanding of the education when which correct statement is
made?
,we should remind the client to turn the head to scan the lost visual field.
The client scheduled for surgery is confused and shows signs of dementia. There is no
advance directive of file designating a pow of attorney for health care. The nurse should
ask which person to sign the consent for the client.
Spouse
The nurse assesses a client with drainage from the nose following a basilar skull
fracture. Which evaluation by the nurse helps positively identify the drainage as
cerebrospinal fluid?
The fluid separates into concentric rigs and tests positive for glucose
A client receives fluid resuscitation per the parkland formula after a severe burn and
continues to have urine output ranging from 20-25ml/hr. After the health care provider
checks the client, which order does the nurse question?
Administer furosemide 40mg iv push
A nurse assesses a client with a long history of seizure disorder. Which manifestation
does the nurse understand is a typical reaction to long-term phenytoin sodium therapy?
Excessive growth of gum tissue
A client with a head injury regains consciousness after several days. When the client
first awakes what should the nurse say to the client
You are in the hospital. You were in an accident and unconscious
On a hot, humid day. A client arrives at the emergency department presenting with
confusion, lethargy, and the following vitals temperature 104.1 degrees F, pulse, 132
, beats/min, respirations 26 breaths/min, and blood pressure 106/66. what is the most
appropriate intervention for this client?
Start an intervenous line and infuse 0.9% saline solution
A nurse assesses a client's surgical incision for signs of infection. Which finding by the
nurse is interpreted as a normal finding at the surgical site?
Serous drainage
A client with hypotension and an elevated temperature after working outside on a hot
day is treated in the emergency department. The nurse determines that discharge
teaching has been effective when the client makes which statement?
I should drink electrolyte sports drinks when working outside in the hot weather
A triage officer is discussing mass casualty triage during a tabletop disaster drill. which
statement indicates further education is needed
Client is the urgent category would include shock and airway obstruction
The nurse is caring for the client, who begins to experience seizure activity while in bed.
Which of the following actions by the nurse would be contraindicated?
Restraining the client's limbs
A client is on intravenous heparin to treat a pulmonary embolism. The client reports
bleeding gums and PTT was 120 seconds
Stop the heparin and notify the healthcare provider
An emergency department charge nurse notes an increase in sick calls and bickering
among the staff after a week with multiple trauma incidents. which actions would the
nurse take?
Answers
The client recovering from a head injury is arousable and participating in care. Which
of the following demonstrates effective client teaching in preventing intracranial
pressure?
Maintain an elevated head of the bed to 30 degrees
The spouse of a 67-year-old male patient with early-stage Alzheimer's disease (AD) tells
the nurse, "I am exhausted from worrying all the time. I do not know what to do."
Which actions are best for the nurse to take next (select all that apply)?
Offer ideas for ways to distract or redirect the patient.
Teach the spouse about adult day care as a possible respite.
Ask the spouse what she knows and has considered about dementia care options.
The high-pressure alarm sounds on a ventilator. AfterAfter looking over the client and
the ventilator, the nurse takes what action next?
Suctions the client to remove excess excretions
The client has returned to the surgical unit from the post-anesthesia unit. The client's
respirations are rapid and shallow, the pulse is 120 beats/min, and the blood pressure is
88/52 the client's LOC is declining. what should the nurse do first?
Call the rapid response team/ Medical emergency team
The nurse has instructed the family of a client who has had a stroke and has
homonymous hemianopsia about measures to help the client overcome the deficit. the
nurse determines the understanding of the education when which correct statement is
made?
,we should remind the client to turn the head to scan the lost visual field.
The client scheduled for surgery is confused and shows signs of dementia. There is no
advance directive of file designating a pow of attorney for health care. The nurse should
ask which person to sign the consent for the client.
Spouse
The nurse assesses a client with drainage from the nose following a basilar skull
fracture. Which evaluation by the nurse helps positively identify the drainage as
cerebrospinal fluid?
The fluid separates into concentric rigs and tests positive for glucose
A client receives fluid resuscitation per the parkland formula after a severe burn and
continues to have urine output ranging from 20-25ml/hr. After the health care provider
checks the client, which order does the nurse question?
Administer furosemide 40mg iv push
A nurse assesses a client with a long history of seizure disorder. Which manifestation
does the nurse understand is a typical reaction to long-term phenytoin sodium therapy?
Excessive growth of gum tissue
A client with a head injury regains consciousness after several days. When the client
first awakes what should the nurse say to the client
You are in the hospital. You were in an accident and unconscious
On a hot, humid day. A client arrives at the emergency department presenting with
confusion, lethargy, and the following vitals temperature 104.1 degrees F, pulse, 132
, beats/min, respirations 26 breaths/min, and blood pressure 106/66. what is the most
appropriate intervention for this client?
Start an intervenous line and infuse 0.9% saline solution
A nurse assesses a client's surgical incision for signs of infection. Which finding by the
nurse is interpreted as a normal finding at the surgical site?
Serous drainage
A client with hypotension and an elevated temperature after working outside on a hot
day is treated in the emergency department. The nurse determines that discharge
teaching has been effective when the client makes which statement?
I should drink electrolyte sports drinks when working outside in the hot weather
A triage officer is discussing mass casualty triage during a tabletop disaster drill. which
statement indicates further education is needed
Client is the urgent category would include shock and airway obstruction
The nurse is caring for the client, who begins to experience seizure activity while in bed.
Which of the following actions by the nurse would be contraindicated?
Restraining the client's limbs
A client is on intravenous heparin to treat a pulmonary embolism. The client reports
bleeding gums and PTT was 120 seconds
Stop the heparin and notify the healthcare provider
An emergency department charge nurse notes an increase in sick calls and bickering
among the staff after a week with multiple trauma incidents. which actions would the
nurse take?
