,NUR 2502 / NUR 2502 Exam 3
Multidimensional Care III (MDC III) |
Rasmussen University | 2026/2027 Exam Prep
+ Clinical Judgment Q&A
Q1. A client with acute decompensated heart failure is prescribed furosemide and digoxin.
Which laboratory value is most important for the nurse to monitor to prevent digoxin
toxicity?
A. Serum sodium
B. Serum potassium
C. Serum calcium
D. Serum magnesium
Correct Answer: B. Serum potassium
Rationale: Furosemide is a loop diuretic that causes potassium loss (hypokalemia).
Hypokalemia potentiates digoxin toxicity by increasing the binding of digoxin to cardiac
sodium-potassium ATPase pumps. Potassium levels should be maintained between 3.5 and
5.0 mEq/L. Serum sodium, calcium, and magnesium are important but do not directly
increase digoxin toxicity risk. The nurse should also monitor the apical pulse and serum
digoxin level.
Key Takeaway: Hypokalemia from loop diuretics increases the risk of digoxin toxicity; monitor
serum potassium.
Q2. A client with heart failure has a brain natriuretic peptide level of 1,850 pg/mL and reports
orthopnea. Which action should the nurse take first?
A. Administer IV furosemide as prescribed
B. Place the client in high-Fowler position
C. Obtain a daily weight
D. Restrict fluid intake
,Correct Answer: B. Place the client in high-Fowler position
Rationale: The client is experiencing acute decompensated heart failure with pulmonary
congestion. The priority is to position the client upright (high-Fowler) to promote maximum
lung expansion and decrease venous return to the heart, improving oxygenation.
Administering furosemide is appropriate but follows positioning and oxygenation. Daily
weight and fluid restriction are important but do not address the immediate respiratory
distress. The nurse should also administer oxygen and monitor respiratory status.
Key Takeaway: Position the client upright first in acute heart failure to improve oxygenation.
Q3. A client receiving chemotherapy for leukemia has a neutrophil count of 400 cells/mm³
and develops a fever of 38.5°C. Which action should the nurse take first?
A. Administer acetaminophen for fever
B. Obtain blood cultures and notify the provider
C. Place the client in a private room
D. Encourage oral fluids
Correct Answer: B. Obtain blood cultures and notify the provider
Rationale: Febrile neutropenia is a medical emergency. Blood cultures and empiric broad-
spectrum antibiotics must be initiated within 1 hour. The nurse should obtain blood cultures
before administering antibiotics and notify the provider immediately. Acetaminophen masks
the fever and delays diagnosis. Placing the client in a private room and encouraging fluids are
supportive but not the priority. The nurse should also implement neutropenic precautions.
Key Takeaway: Febrile neutropenia requires immediate blood cultures and provider
notification for suspected sepsis.
Q4. A client with a spinal cord injury at T5 develops a severe headache, blood pressure
220/118 mm Hg, and heart rate 48 beats/min. Which action should the nurse take first?
A. Administer antihypertensive medication
B. Elevate the head of the bed to 90 degrees
C. Insert a urinary catheter
D. Perform a rectal examination
, Correct Answer: B. Elevate the head of the bed to 90 degrees
Rationale: Autonomic dysreflexia is a life-threatening emergency in clients with spinal cord
injuries at or above T6. It is triggered by a noxious stimulus below the level of injury, most
commonly a distended bladder. The first action is to elevate the head of the bed to 90 degrees
to reduce intracranial pressure and lower blood pressure. Then the nurse should identify and
remove the trigger. Antihypertensive medication may be needed if blood pressure remains
elevated. Rectal examination can worsen the condition.
Key Takeaway: Elevate the head of the bed first for autonomic dysreflexia, then remove the
trigger.
Q5. A client with cirrhosis has a serum ammonia level of 210 mcg/dL and increasing
confusion. Which medication should the nurse anticipate administering?
A. Lactulose
B. Furosemide
C. Spironolactone
D. Propranolol
Correct Answer: A. Lactulose
Rationale: Hepatic encephalopathy occurs when the damaged liver cannot convert ammonia
to urea. Lactulose is a laxative that traps ammonia in the gut and promotes its excretion in the
stool, reducing serum ammonia levels. Furosemide and spironolactone are diuretics used for
ascites. Propranolol is used for portal hypertension prophylaxis. The nurse should also
monitor for improvement in mental status and ammonia levels.
Key Takeaway: Lactulose reduces ammonia levels in hepatic encephalopathy.
Q6. A client with heart failure is prescribed carvedilol. Which assessment finding requires the
nurse to hold the medication and notify the provider?
A. Blood pressure 118/72 mm Hg
B. Heart rate 52 beats/min
C. Respiratory rate 18 breaths/min
D. Oxygen saturation 94%
Multidimensional Care III (MDC III) |
Rasmussen University | 2026/2027 Exam Prep
+ Clinical Judgment Q&A
Q1. A client with acute decompensated heart failure is prescribed furosemide and digoxin.
Which laboratory value is most important for the nurse to monitor to prevent digoxin
toxicity?
A. Serum sodium
B. Serum potassium
C. Serum calcium
D. Serum magnesium
Correct Answer: B. Serum potassium
Rationale: Furosemide is a loop diuretic that causes potassium loss (hypokalemia).
Hypokalemia potentiates digoxin toxicity by increasing the binding of digoxin to cardiac
sodium-potassium ATPase pumps. Potassium levels should be maintained between 3.5 and
5.0 mEq/L. Serum sodium, calcium, and magnesium are important but do not directly
increase digoxin toxicity risk. The nurse should also monitor the apical pulse and serum
digoxin level.
Key Takeaway: Hypokalemia from loop diuretics increases the risk of digoxin toxicity; monitor
serum potassium.
Q2. A client with heart failure has a brain natriuretic peptide level of 1,850 pg/mL and reports
orthopnea. Which action should the nurse take first?
A. Administer IV furosemide as prescribed
B. Place the client in high-Fowler position
C. Obtain a daily weight
D. Restrict fluid intake
,Correct Answer: B. Place the client in high-Fowler position
Rationale: The client is experiencing acute decompensated heart failure with pulmonary
congestion. The priority is to position the client upright (high-Fowler) to promote maximum
lung expansion and decrease venous return to the heart, improving oxygenation.
Administering furosemide is appropriate but follows positioning and oxygenation. Daily
weight and fluid restriction are important but do not address the immediate respiratory
distress. The nurse should also administer oxygen and monitor respiratory status.
Key Takeaway: Position the client upright first in acute heart failure to improve oxygenation.
Q3. A client receiving chemotherapy for leukemia has a neutrophil count of 400 cells/mm³
and develops a fever of 38.5°C. Which action should the nurse take first?
A. Administer acetaminophen for fever
B. Obtain blood cultures and notify the provider
C. Place the client in a private room
D. Encourage oral fluids
Correct Answer: B. Obtain blood cultures and notify the provider
Rationale: Febrile neutropenia is a medical emergency. Blood cultures and empiric broad-
spectrum antibiotics must be initiated within 1 hour. The nurse should obtain blood cultures
before administering antibiotics and notify the provider immediately. Acetaminophen masks
the fever and delays diagnosis. Placing the client in a private room and encouraging fluids are
supportive but not the priority. The nurse should also implement neutropenic precautions.
Key Takeaway: Febrile neutropenia requires immediate blood cultures and provider
notification for suspected sepsis.
Q4. A client with a spinal cord injury at T5 develops a severe headache, blood pressure
220/118 mm Hg, and heart rate 48 beats/min. Which action should the nurse take first?
A. Administer antihypertensive medication
B. Elevate the head of the bed to 90 degrees
C. Insert a urinary catheter
D. Perform a rectal examination
, Correct Answer: B. Elevate the head of the bed to 90 degrees
Rationale: Autonomic dysreflexia is a life-threatening emergency in clients with spinal cord
injuries at or above T6. It is triggered by a noxious stimulus below the level of injury, most
commonly a distended bladder. The first action is to elevate the head of the bed to 90 degrees
to reduce intracranial pressure and lower blood pressure. Then the nurse should identify and
remove the trigger. Antihypertensive medication may be needed if blood pressure remains
elevated. Rectal examination can worsen the condition.
Key Takeaway: Elevate the head of the bed first for autonomic dysreflexia, then remove the
trigger.
Q5. A client with cirrhosis has a serum ammonia level of 210 mcg/dL and increasing
confusion. Which medication should the nurse anticipate administering?
A. Lactulose
B. Furosemide
C. Spironolactone
D. Propranolol
Correct Answer: A. Lactulose
Rationale: Hepatic encephalopathy occurs when the damaged liver cannot convert ammonia
to urea. Lactulose is a laxative that traps ammonia in the gut and promotes its excretion in the
stool, reducing serum ammonia levels. Furosemide and spironolactone are diuretics used for
ascites. Propranolol is used for portal hypertension prophylaxis. The nurse should also
monitor for improvement in mental status and ammonia levels.
Key Takeaway: Lactulose reduces ammonia levels in hepatic encephalopathy.
Q6. A client with heart failure is prescribed carvedilol. Which assessment finding requires the
nurse to hold the medication and notify the provider?
A. Blood pressure 118/72 mm Hg
B. Heart rate 52 beats/min
C. Respiratory rate 18 breaths/min
D. Oxygen saturation 94%
