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NUR2755 Final Exam
2024/2025 – Multidimensional
Care IV (MDC 4) | Rasmussen
| Verified and Updated
Questions
Question 1
A client in septic shock has a mean arterial pressure (MAP) of 55 mmHg. Which intervention
should the nurse prioritize?
A. Administer an antipyretic for fever
B. Initiate norepinephrine infusion
C. Apply a cooling blanket
D. Administer a bolus of 500 mL normal saline
Correct Answer: D. Administer a bolus of 500 mL normal saline
Rationale: A MAP <65 mmHg in septic shock indicates hypoperfusion. Per MDC 4 shock
management, fluid resuscitation with crystalloids (e.g., 500 mL normal saline bolus) is the
priority to restore intravascular volume before vasopressors like norepinephrine.
Question 2
A client with traumatic brain injury has an intracranial pressure (ICP) of 25 mmHg. Which
action should the nurse take first?
A. Administer mannitol IV
B. Hyperventilate the client
C. Elevate the head of the bed to 30 degrees
D. Notify the healthcare provider
Correct Answer: C. Elevate the head of the bed to 30 degrees
Rationale: An ICP >20 mmHg is elevated. Elevating the head of the bed to 30 degrees promotes
, 2
venous drainage to reduce ICP, a priority per MDC 4 neurological care objectives. Mannitol and
hyperventilation require orders, and notification follows initial intervention.
Question 3
A client presents with tachycardia, hypotension, and cool, clammy skin after a motor vehicle
accident. Which type of shock should the nurse suspect?
A. Cardiogenic
B. Hypovolemic
C. Neurogenic
D. Anaphylactic
Correct Answer: B. Hypovolemic
Rationale: Hypotension, tachycardia, and cool, clammy skin indicate hypovolemic shock due to
blood loss, common in trauma, per MDC 4 shock assessment objectives.
Question 4
A client with a 35% total body surface area (TBSA) burn is in the emergent phase. How much
fluid should be administered in the first 8 hours using the Parkland formula (client weight: 80
kg)?
A. 2,800 mL
B. 5,600 mL
C. 7,000 mL
D. 8,400 mL
Correct Answer: B. 5,600 mL
Rationale: The Parkland formula is 4 mL/kg/% TBSA, with half given in the first 8 hours. For
80 kg and 35% TBSA: 4 × 80 × 35 = 11,200 mL total; 11,200 ÷ 2 = 5,600 mL in the first 8
hours, per MDC 4 burn care objectives.
Question 5
A client in the emergency department has a Glasgow Coma Scale (GCS) score of 7. Which
action should the nurse prioritize?
A. Obtain a CT scan
B. Prepare for intubation
C. Administer pain medication
D. Apply a cervical collar
, 3
Correct Answer: B. Prepare for intubation
Rationale: A GCS score ≤8 indicates severe neurological impairment, requiring immediate
airway protection via intubation, per MDC 4 emergency care objectives.
Question 6
A client with severe burns develops a serum potassium level of 5.8 mEq/L. Which complication
should the nurse suspect?
A. Hypokalemia
B. Hyperkalemia
C. Hyponatremia
D. Hypocalcemia
Correct Answer: B. Hyperkalemia
Rationale: Severe burns cause cell lysis, releasing potassium into the bloodstream, leading to
hyperkalemia, a focus of MDC 4 burn care objectives.
Question 7
A client with acute respiratory distress syndrome (ARDS) has a PaO2/FiO2 ratio of 150. Which
ventilator setting should the nurse expect?
A. Increased tidal volume
B. Positive end-expiratory pressure (PEEP)
C. Decreased respiratory rate
D. High-frequency oscillatory ventilation
Correct Answer: B. Positive end-expiratory pressure (PEEP)
Rationale: A PaO2/FiO2 ratio <200 indicates severe ARDS. PEEP prevents alveolar collapse,
improving oxygenation, per MDC 4 critical care objectives.
Question 8
A client with a C6 spinal cord injury is at risk for which complication?
A. Autonomic dysreflexia
B. Respiratory failure
C. Seizures
D. Cerebral edema
NUR2755 Final Exam
2024/2025 – Multidimensional
Care IV (MDC 4) | Rasmussen
| Verified and Updated
Questions
Question 1
A client in septic shock has a mean arterial pressure (MAP) of 55 mmHg. Which intervention
should the nurse prioritize?
A. Administer an antipyretic for fever
B. Initiate norepinephrine infusion
C. Apply a cooling blanket
D. Administer a bolus of 500 mL normal saline
Correct Answer: D. Administer a bolus of 500 mL normal saline
Rationale: A MAP <65 mmHg in septic shock indicates hypoperfusion. Per MDC 4 shock
management, fluid resuscitation with crystalloids (e.g., 500 mL normal saline bolus) is the
priority to restore intravascular volume before vasopressors like norepinephrine.
Question 2
A client with traumatic brain injury has an intracranial pressure (ICP) of 25 mmHg. Which
action should the nurse take first?
A. Administer mannitol IV
B. Hyperventilate the client
C. Elevate the head of the bed to 30 degrees
D. Notify the healthcare provider
Correct Answer: C. Elevate the head of the bed to 30 degrees
Rationale: An ICP >20 mmHg is elevated. Elevating the head of the bed to 30 degrees promotes
, 2
venous drainage to reduce ICP, a priority per MDC 4 neurological care objectives. Mannitol and
hyperventilation require orders, and notification follows initial intervention.
Question 3
A client presents with tachycardia, hypotension, and cool, clammy skin after a motor vehicle
accident. Which type of shock should the nurse suspect?
A. Cardiogenic
B. Hypovolemic
C. Neurogenic
D. Anaphylactic
Correct Answer: B. Hypovolemic
Rationale: Hypotension, tachycardia, and cool, clammy skin indicate hypovolemic shock due to
blood loss, common in trauma, per MDC 4 shock assessment objectives.
Question 4
A client with a 35% total body surface area (TBSA) burn is in the emergent phase. How much
fluid should be administered in the first 8 hours using the Parkland formula (client weight: 80
kg)?
A. 2,800 mL
B. 5,600 mL
C. 7,000 mL
D. 8,400 mL
Correct Answer: B. 5,600 mL
Rationale: The Parkland formula is 4 mL/kg/% TBSA, with half given in the first 8 hours. For
80 kg and 35% TBSA: 4 × 80 × 35 = 11,200 mL total; 11,200 ÷ 2 = 5,600 mL in the first 8
hours, per MDC 4 burn care objectives.
Question 5
A client in the emergency department has a Glasgow Coma Scale (GCS) score of 7. Which
action should the nurse prioritize?
A. Obtain a CT scan
B. Prepare for intubation
C. Administer pain medication
D. Apply a cervical collar
, 3
Correct Answer: B. Prepare for intubation
Rationale: A GCS score ≤8 indicates severe neurological impairment, requiring immediate
airway protection via intubation, per MDC 4 emergency care objectives.
Question 6
A client with severe burns develops a serum potassium level of 5.8 mEq/L. Which complication
should the nurse suspect?
A. Hypokalemia
B. Hyperkalemia
C. Hyponatremia
D. Hypocalcemia
Correct Answer: B. Hyperkalemia
Rationale: Severe burns cause cell lysis, releasing potassium into the bloodstream, leading to
hyperkalemia, a focus of MDC 4 burn care objectives.
Question 7
A client with acute respiratory distress syndrome (ARDS) has a PaO2/FiO2 ratio of 150. Which
ventilator setting should the nurse expect?
A. Increased tidal volume
B. Positive end-expiratory pressure (PEEP)
C. Decreased respiratory rate
D. High-frequency oscillatory ventilation
Correct Answer: B. Positive end-expiratory pressure (PEEP)
Rationale: A PaO2/FiO2 ratio <200 indicates severe ARDS. PEEP prevents alveolar collapse,
improving oxygenation, per MDC 4 critical care objectives.
Question 8
A client with a C6 spinal cord injury is at risk for which complication?
A. Autonomic dysreflexia
B. Respiratory failure
C. Seizures
D. Cerebral edema
