Rasmussen College MDC 2 Exam 1 Study Guide
(2026/2027)
1. A nurse is caring for a client who has a circumferential burn to the
right arm. Which of the following findings is the priority to report to the
provider?
A) Pain rating of 8 on a scale of 0 to 10
B) Edema of the right hand and fingers
C) Capillary refill of 3 seconds in the right fingernails
D) Partial-thickness blisters on the upper arm
Answer: C) Capillary refill of 3 seconds in the right fingernails
Rationale: A circumferential burn can act as a tourniquet as edema
develops, leading to compartment syndrome and compromised
circulation. A delayed capillary refill (>2 seconds) indicates vascular
compromise and requires an immediate escharotomy to save the limb.
2. A nurse is assessing a client who is receiving total parenteral nutrition
(TPN) and notes that the client has polyuria, excessive thirst, and
confusion. Which of the following complications should the nurse
suspect?
A) Hypoglycemia
B) Hyperglycemia
C) Air embolism
D) Catheter-related sepsis
,Answer: B) Hyperglycemia
Rationale: TPN solutions have a high dextrose concentration.
Administering it too rapidly or the client having impaired glucose
tolerance can lead to hyperglycemia, manifesting as polyuria,
polydipsia, and confusion.
3. A nurse is caring for a client who has acute respiratory distress
syndrome (ARDS) and is receiving mechanical ventilation. Which of the
following ventilator settings is most important for the nurse to monitor
to prevent barotrauma?
A) Tidal volume
B) Positive end-expiratory pressure (PEEP)
C) Fraction of inspired oxygen (FiO2)
D) Respiratory rate
Answer: B) Positive end-expiratory pressure (PEEP)
Rationale: While high tidal volumes can cause volutrauma, high PEEP is
specifically associated with barotrauma (pneumothorax) because it
keeps the alveoli open under high pressure. ARDS requires high PEEP to
recruit collapsed alveoli, but it must be monitored closely.
4. A nurse is caring for a client with a chest tube attached to a water-
seal drainage system. The nurse notes continuous bubbling in the
water-seal chamber. Which of the following actions should the nurse
take?
,A) Clamp the chest tube
B) Check the system for an air leak
C) Add more water to the suction control chamber
D) Document the finding as expected
Answer: B) Check the system for an air leak
Rationale: Continuous bubbling in the water-seal chamber indicates an
air leak in the system (at the insertion site, tubing, or connections).
Intermittent bubbling is normal, but continuous bubbling requires
investigation. Clamping the chest tube is done only to locate the leak,
not as a continuous intervention.
5. A client is admitted with severe vomiting and diarrhea. The client's
blood pressure is 88/52 mmHg, heart rate is 120/min, and urine output
is 15 mL/hr. Which of the following isotonic IV solutions should the
nurse anticipate administering?
A) Dextrose 5% in Water (D5W)
B) 0.45% Sodium Chloride (Half Normal Saline)
C) 0.9% Sodium Chloride (Normal Saline)
D) Lactated Ringer's (LR)
Answer: D) Lactated Ringer's (LR)
Rationale: The client is in hypovolemic shock due to fluid loss. Lactated
Ringer's is the preferred crystalloid for hypovolemic shock because it
contains electrolytes and buffers (lactate) that help correct metabolic
, acidosis associated with shock. Normal saline is also acceptable, but LR
is the best choice.
6. A nurse is caring for a client who has liver cirrhosis and ascites. Which
of the following interventions should the nurse implement to manage
the ascites?
A) Restrict fluid intake to 3,000 mL/day
B) Administer furosemide (Lasix) and spironolactone (Aldactone)
C) Encourage a high-sodium diet
D) Position the client in a supine position
Answer: B) Administer furosemide (Lasix) and spironolactone
(Aldactone)
Rationale: Spironolactone (potassium-sparing) and furosemide
(potassium-wasting) are given together to promote diuresis of the
ascitic fluid while maintaining potassium balance. Fluid and sodium are
restricted, and the client should be positioned in semi-Fowler's to aid
breathing.
7. A nurse is caring for a client with disseminated intravascular
coagulation (DIC). Which of the following laboratory findings should the
nurse expect?
A) Prolonged PT and PTT
B) Increased platelet count
C) Decreased D-dimer
(2026/2027)
1. A nurse is caring for a client who has a circumferential burn to the
right arm. Which of the following findings is the priority to report to the
provider?
A) Pain rating of 8 on a scale of 0 to 10
B) Edema of the right hand and fingers
C) Capillary refill of 3 seconds in the right fingernails
D) Partial-thickness blisters on the upper arm
Answer: C) Capillary refill of 3 seconds in the right fingernails
Rationale: A circumferential burn can act as a tourniquet as edema
develops, leading to compartment syndrome and compromised
circulation. A delayed capillary refill (>2 seconds) indicates vascular
compromise and requires an immediate escharotomy to save the limb.
2. A nurse is assessing a client who is receiving total parenteral nutrition
(TPN) and notes that the client has polyuria, excessive thirst, and
confusion. Which of the following complications should the nurse
suspect?
A) Hypoglycemia
B) Hyperglycemia
C) Air embolism
D) Catheter-related sepsis
,Answer: B) Hyperglycemia
Rationale: TPN solutions have a high dextrose concentration.
Administering it too rapidly or the client having impaired glucose
tolerance can lead to hyperglycemia, manifesting as polyuria,
polydipsia, and confusion.
3. A nurse is caring for a client who has acute respiratory distress
syndrome (ARDS) and is receiving mechanical ventilation. Which of the
following ventilator settings is most important for the nurse to monitor
to prevent barotrauma?
A) Tidal volume
B) Positive end-expiratory pressure (PEEP)
C) Fraction of inspired oxygen (FiO2)
D) Respiratory rate
Answer: B) Positive end-expiratory pressure (PEEP)
Rationale: While high tidal volumes can cause volutrauma, high PEEP is
specifically associated with barotrauma (pneumothorax) because it
keeps the alveoli open under high pressure. ARDS requires high PEEP to
recruit collapsed alveoli, but it must be monitored closely.
4. A nurse is caring for a client with a chest tube attached to a water-
seal drainage system. The nurse notes continuous bubbling in the
water-seal chamber. Which of the following actions should the nurse
take?
,A) Clamp the chest tube
B) Check the system for an air leak
C) Add more water to the suction control chamber
D) Document the finding as expected
Answer: B) Check the system for an air leak
Rationale: Continuous bubbling in the water-seal chamber indicates an
air leak in the system (at the insertion site, tubing, or connections).
Intermittent bubbling is normal, but continuous bubbling requires
investigation. Clamping the chest tube is done only to locate the leak,
not as a continuous intervention.
5. A client is admitted with severe vomiting and diarrhea. The client's
blood pressure is 88/52 mmHg, heart rate is 120/min, and urine output
is 15 mL/hr. Which of the following isotonic IV solutions should the
nurse anticipate administering?
A) Dextrose 5% in Water (D5W)
B) 0.45% Sodium Chloride (Half Normal Saline)
C) 0.9% Sodium Chloride (Normal Saline)
D) Lactated Ringer's (LR)
Answer: D) Lactated Ringer's (LR)
Rationale: The client is in hypovolemic shock due to fluid loss. Lactated
Ringer's is the preferred crystalloid for hypovolemic shock because it
contains electrolytes and buffers (lactate) that help correct metabolic
, acidosis associated with shock. Normal saline is also acceptable, but LR
is the best choice.
6. A nurse is caring for a client who has liver cirrhosis and ascites. Which
of the following interventions should the nurse implement to manage
the ascites?
A) Restrict fluid intake to 3,000 mL/day
B) Administer furosemide (Lasix) and spironolactone (Aldactone)
C) Encourage a high-sodium diet
D) Position the client in a supine position
Answer: B) Administer furosemide (Lasix) and spironolactone
(Aldactone)
Rationale: Spironolactone (potassium-sparing) and furosemide
(potassium-wasting) are given together to promote diuresis of the
ascitic fluid while maintaining potassium balance. Fluid and sodium are
restricted, and the client should be positioned in semi-Fowler's to aid
breathing.
7. A nurse is caring for a client with disseminated intravascular
coagulation (DIC). Which of the following laboratory findings should the
nurse expect?
A) Prolonged PT and PTT
B) Increased platelet count
C) Decreased D-dimer
