NUR2755 / NUR 2755 FINAL EXAM MULTIDIMENSIONAL
CARE IV / MDC 4 – RASMUSSEN COMPLETE PRACTICE
QUESTIONS WITH VERIFIED ANSWERS
1. A nurse is assessing a patient with suspected cardiovascular
compromise. Which finding requires immediate intervention?
A) Blood pressure 110/70 mmHg
B) Heart rate 88 beats per minute
C) Jugular venous distention
D) Capillary refill less than 2 seconds
Answer: C
Rationale: Jugular venous distention indicates increased central venous
pressure and right-sided heart failure, suggesting fluid overload or
cardiac dysfunction requiring immediate intervention. Normal capillary
refill is <2 seconds, and the other vitals are within normal limits.
2. A patient with a clotting disorder has an INR of 4.5. Which
medication should the nurse anticipate administering?
A) Vitamin K
B) Heparin
C) Enoxaparin
D) Aspirin
Answer: A
Rationale: An INR of 4.5 is elevated above the therapeutic range
,(typically 2.0–3.0 for most indications). Vitamin K is the antidote for
warfarin overdose to reverse excessive anticoagulation.
3. A patient presents with muscle cramps, confusion, and irregular
heart rate. Lab results show sodium 130 mEq/L and potassium 2.8
mEq/L. Which intervention is priority?
A) Restrict oral fluids
B) Administer IV potassium replacement
C) Administer normal saline bolus
D) Prepare for hemodialysis
Answer: B
Rationale: Potassium of 2.8 mEq/L is critically low (hypokalemia), which
can cause life-threatening cardiac dysrhythmias. Potassium replacement
is the priority. Sodium is mildly low but less immediately life-
threatening.
4. A postoperative patient rates pain as 8/10 and refuses opioid
medication due to fear of addiction. Which non-pharmacological
intervention should the nurse implement first?
A) Apply a warm compress
B) Guided imagery and deep breathing
C) Immobilize the surgical site
D) Request a psychiatry consult
Answer: B
Rationale: Guided imagery and deep breathing are immediate, non-
invasive comfort measures that can reduce pain perception without
,medication. They respect the patient's concerns while providing active
relief.
5. An elderly patient with pneumonia has an arterial blood gas
showing pH 7.30, PaCO2 55 mmHg, HCO3 24 mEq/L. Which condition
does this indicate?
A) Metabolic acidosis
B) Metabolic alkalosis
C) Respiratory acidosis
D) Respiratory alkalosis
Answer: C
Rationale: pH is low (acidosis), PaCO2 is elevated (>45 mmHg), and
HCO3 is normal. This indicates respiratory acidosis due to
hypoventilation from pneumonia.
6. A patient with end-stage renal disease has been unable to void for 8
hours. Which assessment finding indicates a complication requiring
immediate action?
A) Serum creatinine 2.1 mg/dL
B) Bladder distention to the umbilicus
C) BUN 42 mg/dL
D) Urine output 30 mL/hr
Answer: B
Rationale: Bladder distention to the umbilicus indicates significant
urinary retention that can lead to autonomic dysreflexia or bladder
rupture. This requires immediate catheterization.
, 7. A surgical wound appears red, warm, and has purulent drainage on
postoperative day 3. Which phase of the inflammatory response is
occurring?
A) Proliferative phase
B) Maturation phase
C) Inflammatory phase
D) Remodeling phase
Answer: C
Rationale: Redness, warmth, and purulent drainage indicate the acute
inflammatory phase, where neutrophils and macrophages respond to
infection or injury. The proliferative phase involves granulation tissue
formation.
8. A patient with a full-thickness burn to the chest and arms is
admitted. Which laboratory finding would the nurse expect in the
early resuscitative phase?
A) Hypernatremia
B) Hyperkalemia
C) Hypokalemia
D) Hypercalcemia
Answer: B
Rationale: In the early phase of major burns, massive cell destruction
releases intracellular potassium into the bloodstream, causing
hyperkalemia. Sodium and calcium are typically altered later.
9. A patient with COPD is receiving oxygen at 2 L/min via nasal
cannula. The nurse notes respiratory rate has decreased to 8
CARE IV / MDC 4 – RASMUSSEN COMPLETE PRACTICE
QUESTIONS WITH VERIFIED ANSWERS
1. A nurse is assessing a patient with suspected cardiovascular
compromise. Which finding requires immediate intervention?
A) Blood pressure 110/70 mmHg
B) Heart rate 88 beats per minute
C) Jugular venous distention
D) Capillary refill less than 2 seconds
Answer: C
Rationale: Jugular venous distention indicates increased central venous
pressure and right-sided heart failure, suggesting fluid overload or
cardiac dysfunction requiring immediate intervention. Normal capillary
refill is <2 seconds, and the other vitals are within normal limits.
2. A patient with a clotting disorder has an INR of 4.5. Which
medication should the nurse anticipate administering?
A) Vitamin K
B) Heparin
C) Enoxaparin
D) Aspirin
Answer: A
Rationale: An INR of 4.5 is elevated above the therapeutic range
,(typically 2.0–3.0 for most indications). Vitamin K is the antidote for
warfarin overdose to reverse excessive anticoagulation.
3. A patient presents with muscle cramps, confusion, and irregular
heart rate. Lab results show sodium 130 mEq/L and potassium 2.8
mEq/L. Which intervention is priority?
A) Restrict oral fluids
B) Administer IV potassium replacement
C) Administer normal saline bolus
D) Prepare for hemodialysis
Answer: B
Rationale: Potassium of 2.8 mEq/L is critically low (hypokalemia), which
can cause life-threatening cardiac dysrhythmias. Potassium replacement
is the priority. Sodium is mildly low but less immediately life-
threatening.
4. A postoperative patient rates pain as 8/10 and refuses opioid
medication due to fear of addiction. Which non-pharmacological
intervention should the nurse implement first?
A) Apply a warm compress
B) Guided imagery and deep breathing
C) Immobilize the surgical site
D) Request a psychiatry consult
Answer: B
Rationale: Guided imagery and deep breathing are immediate, non-
invasive comfort measures that can reduce pain perception without
,medication. They respect the patient's concerns while providing active
relief.
5. An elderly patient with pneumonia has an arterial blood gas
showing pH 7.30, PaCO2 55 mmHg, HCO3 24 mEq/L. Which condition
does this indicate?
A) Metabolic acidosis
B) Metabolic alkalosis
C) Respiratory acidosis
D) Respiratory alkalosis
Answer: C
Rationale: pH is low (acidosis), PaCO2 is elevated (>45 mmHg), and
HCO3 is normal. This indicates respiratory acidosis due to
hypoventilation from pneumonia.
6. A patient with end-stage renal disease has been unable to void for 8
hours. Which assessment finding indicates a complication requiring
immediate action?
A) Serum creatinine 2.1 mg/dL
B) Bladder distention to the umbilicus
C) BUN 42 mg/dL
D) Urine output 30 mL/hr
Answer: B
Rationale: Bladder distention to the umbilicus indicates significant
urinary retention that can lead to autonomic dysreflexia or bladder
rupture. This requires immediate catheterization.
, 7. A surgical wound appears red, warm, and has purulent drainage on
postoperative day 3. Which phase of the inflammatory response is
occurring?
A) Proliferative phase
B) Maturation phase
C) Inflammatory phase
D) Remodeling phase
Answer: C
Rationale: Redness, warmth, and purulent drainage indicate the acute
inflammatory phase, where neutrophils and macrophages respond to
infection or injury. The proliferative phase involves granulation tissue
formation.
8. A patient with a full-thickness burn to the chest and arms is
admitted. Which laboratory finding would the nurse expect in the
early resuscitative phase?
A) Hypernatremia
B) Hyperkalemia
C) Hypokalemia
D) Hypercalcemia
Answer: B
Rationale: In the early phase of major burns, massive cell destruction
releases intracellular potassium into the bloodstream, causing
hyperkalemia. Sodium and calcium are typically altered later.
9. A patient with COPD is receiving oxygen at 2 L/min via nasal
cannula. The nurse notes respiratory rate has decreased to 8
