NUR2356: Multidimensional Care I (MDC I) –
Exam 2 Complete Guide | Rasmussen College |
NCLEX-RN® Clinical Judgment Focus |
2026/2027 Update
CONCEPT CLUSTER 1: Infection, Inflammation, & Immunity (12 questions)
Q1
Stem: A 68-year-old client hospitalized for community-acquired pneumonia (CAP)
receives the first dose of IV ceftriaxone. Within 15 min the nurse notes a new
widespread maculopapular rash and the client reports “my throat feels tight.” Vital
signs: BP 88/50, HR 122, RR 28, SpO₂ 92% on 2 L NC. Which action is MOST important?
A. Stop the infusion and prepare epinephrine 0.5 mg IM.
B. Slow the infusion rate and apply cool compresses.
C. Document the reaction and obtain a blood culture.
D. Give diphenhydramine 25 mg PO and continue the dose.
Verified Answer & Complete Guide
Correct Answer: A
Why This is Correct: Rapid-onset rash, throat tightness, and hypotension signal
anaphylaxis; immediate drug discontinuation and epinephrine are the standard of care.
,Clinical Judgment Cue Analysis: Time (15 min after new drug) + constellation of skin,
airway, and circulatory symptoms = anaphylaxis until proven otherwise.
Why the Others Are Wrong:
B: Slowing the infusion prolongs allergen exposure.
C: Blood cultures are for infection, not acute allergy.
D: PO diphenhydramine is too slow; continuing the dose is unsafe.
Takeaway for Practice: Any new skin reaction plus airway or hemodynamic change after
medication administration equals stop drug-call for help-give epinephrine.
Q2
Stem: Post-op day 2 after abdominal surgery, the client’s incision is warm,
erythematous, and tender without purulent drainage. Temp 37.9 °C (100.2 °F), WBC 11
000/µL. Which nursing action is BEST?
A. Obtain wound cultures immediately.
B. Apply a sterile warm compress and reassess in 4 h.
C. Initiate contact precautions.
D. Administer PRN acetaminophen 650 mg PO.
Correct Answer: B
Why This is Correct: Classic localized inflammation; warm compress increases blood
flow and resolution. No evidence of infection (no fever >38.3 °C, no purulence).
,Cue Analysis: Warmth + redness + pain = inflammation; absence of purulent drainage or
high fever rules out infection at this point.
Why the Others Are Wrong:
A: Culturing non-purulent tissue yields false positives.
C: Contact precautions require documented or suspected infection.
D: Treating the symptom (low-grade temp) does not address the underlying process.
Takeaway for Practice: Inflammation presents with localized redness, warmth, and
swelling; infection presents with these plus purulent drainage and systemic signs like
fever.
Q3
Stem: A nurse is teaching a female client diagnosed with an uncomplicated UTI
prescribed nitrofurantoin 100 mg BID × 5 days. Which statement by the client indicates
understanding?
A. “I will stop the antibiotic when the burning stops.”
B. “I should take each dose with food or milk.”
C. “I need to drink cranberry juice instead of water.”
D. “I will double my dose if I miss one.”
Correct Answer: B
Why This is Correct: Food or milk improves nitrofurantoin absorption and decreases GI
upset.
, Cue Analysis: Teaching focus = antibiotic adherence and tolerance; only B addresses
standard administration instruction.
Why the Others Are Wrong:
A: Early discontinuation risks relapse and resistance.
C: Cranberry is adjunctive, not a substitute for fluids or drugs.
D: Double-dosing increases toxicity risk.
Takeaway for Practice: Antibiotics for UTI must be taken with food/milk to enhance
absorption and reduce nausea.
Q4
Stem: A client in isolation for influenza A receives a meal tray. After retrieving the tray,
which action by the nurse maintains droplet precautions?
A. Wears an N95 respirator while inside the room.
B. Keeps the door closed and positions the tray on the bedside table.
C. Disinfects the outer tray surface before leaving the room.
D. Places the used tray on the floor outside the doorway.
Correct Answer: B
Why This is Correct: Droplet precautions require door closure to contain respiratory
droplets; minimizing items leaving the room reduces pathogen spread.
Cue Analysis: “Droplet precautions” + “meal tray” = focus on containment, not
necessarily airborne PPE.
Exam 2 Complete Guide | Rasmussen College |
NCLEX-RN® Clinical Judgment Focus |
2026/2027 Update
CONCEPT CLUSTER 1: Infection, Inflammation, & Immunity (12 questions)
Q1
Stem: A 68-year-old client hospitalized for community-acquired pneumonia (CAP)
receives the first dose of IV ceftriaxone. Within 15 min the nurse notes a new
widespread maculopapular rash and the client reports “my throat feels tight.” Vital
signs: BP 88/50, HR 122, RR 28, SpO₂ 92% on 2 L NC. Which action is MOST important?
A. Stop the infusion and prepare epinephrine 0.5 mg IM.
B. Slow the infusion rate and apply cool compresses.
C. Document the reaction and obtain a blood culture.
D. Give diphenhydramine 25 mg PO and continue the dose.
Verified Answer & Complete Guide
Correct Answer: A
Why This is Correct: Rapid-onset rash, throat tightness, and hypotension signal
anaphylaxis; immediate drug discontinuation and epinephrine are the standard of care.
,Clinical Judgment Cue Analysis: Time (15 min after new drug) + constellation of skin,
airway, and circulatory symptoms = anaphylaxis until proven otherwise.
Why the Others Are Wrong:
B: Slowing the infusion prolongs allergen exposure.
C: Blood cultures are for infection, not acute allergy.
D: PO diphenhydramine is too slow; continuing the dose is unsafe.
Takeaway for Practice: Any new skin reaction plus airway or hemodynamic change after
medication administration equals stop drug-call for help-give epinephrine.
Q2
Stem: Post-op day 2 after abdominal surgery, the client’s incision is warm,
erythematous, and tender without purulent drainage. Temp 37.9 °C (100.2 °F), WBC 11
000/µL. Which nursing action is BEST?
A. Obtain wound cultures immediately.
B. Apply a sterile warm compress and reassess in 4 h.
C. Initiate contact precautions.
D. Administer PRN acetaminophen 650 mg PO.
Correct Answer: B
Why This is Correct: Classic localized inflammation; warm compress increases blood
flow and resolution. No evidence of infection (no fever >38.3 °C, no purulence).
,Cue Analysis: Warmth + redness + pain = inflammation; absence of purulent drainage or
high fever rules out infection at this point.
Why the Others Are Wrong:
A: Culturing non-purulent tissue yields false positives.
C: Contact precautions require documented or suspected infection.
D: Treating the symptom (low-grade temp) does not address the underlying process.
Takeaway for Practice: Inflammation presents with localized redness, warmth, and
swelling; infection presents with these plus purulent drainage and systemic signs like
fever.
Q3
Stem: A nurse is teaching a female client diagnosed with an uncomplicated UTI
prescribed nitrofurantoin 100 mg BID × 5 days. Which statement by the client indicates
understanding?
A. “I will stop the antibiotic when the burning stops.”
B. “I should take each dose with food or milk.”
C. “I need to drink cranberry juice instead of water.”
D. “I will double my dose if I miss one.”
Correct Answer: B
Why This is Correct: Food or milk improves nitrofurantoin absorption and decreases GI
upset.
, Cue Analysis: Teaching focus = antibiotic adherence and tolerance; only B addresses
standard administration instruction.
Why the Others Are Wrong:
A: Early discontinuation risks relapse and resistance.
C: Cranberry is adjunctive, not a substitute for fluids or drugs.
D: Double-dosing increases toxicity risk.
Takeaway for Practice: Antibiotics for UTI must be taken with food/milk to enhance
absorption and reduce nausea.
Q4
Stem: A client in isolation for influenza A receives a meal tray. After retrieving the tray,
which action by the nurse maintains droplet precautions?
A. Wears an N95 respirator while inside the room.
B. Keeps the door closed and positions the tray on the bedside table.
C. Disinfects the outer tray surface before leaving the room.
D. Places the used tray on the floor outside the doorway.
Correct Answer: B
Why This is Correct: Droplet precautions require door closure to contain respiratory
droplets; minimizing items leaving the room reduces pathogen spread.
Cue Analysis: “Droplet precautions” + “meal tray” = focus on containment, not
necessarily airborne PPE.
