NUR 2502 / MDC 3 Exam 1 | Rasmussen University | 2026-2027 Page 1
Exam 1 - NUR 2502 / NUR2502
Multidimensional Care III (MDC 3)
Latest | Rasmussen University
Total Questions: 75
Cognitive Levels: 25% Recall / 55% Application / 20% Analysis
Format: Multiple Choice (4 options, 1 correct)
Question Style: 70% Scenario / 20% Recall / 10% Clinical Judgment
Sections: 7 (Oncology, Hematologic, Immunologic, MSK, Integumentary, Neuro, Integrated)
Aligned With: Rasmussen MDC 3 NUR 2502 Curriculum Blueprint
INSTRUCTIONS: This comprehensive examination assesses competency across seven core domains of Multidimensional Care III.
Each question includes the correct answer and a detailed clinical rationale grounded in MDC 3 nursing competencies,
evidence-based practice, and Rasmussen University 2026-2027 curriculum standards. Use the rationales to reinforce
pathophysiologic reasoning and prioritization skills.
Section 1: Oncology Nursing (Cancer Pathophysiology, Staging, Treatment
Modalities, & Nursing Care) (Q1-Q15)
Q1: A 58-year-old female patient asks the nurse to explain how a normal cell transforms into a malignant
cell. The nurse correctly describes the three sequential phases of carcinogenesis in which order?
A. Progression, initiation, promotion
B. Initiation, promotion, progression [CORRECT]
C. Promotion, progression, initiation
D. Initiation, progression, promotion
Correct Answer: B
Rationale:
Carcinogenesis proceeds through initiation (exposure to carcinogen causing irreversible DNA mutation), promotion (reversible
clonal expansion of initiated cells triggered by promoters like hormones or chronic inflammation), and progression (irreversible
conversion to malignant phenotype with invasion and metastasis). This sequence reflects the multistep nature of cancer
development and explains why risk reduction at any phase can interrupt malignant transformation. Reversing the order
misrepresents the biologic cascade central to MDC 3 oncology pathophysiology.
Q2: A patient with a strong family history of breast and ovarian cancer tests positive for a mutation in the
BRCA1 gene. The nurse understands that BRCA1 is classified as which type of gene, and what is its normal
function?
A. Oncogene; stimulates cell division when mutated
B. DNA repair gene; repairs mismatches in base pairing
C. Tumor suppressor gene; inhibits uncontrolled cell growth by repairing DNA damage and regulating cell cycle
arrest [CORRECT]
D. Promoter gene; initiates transcription of growth factors
Correct Answer: C
Rationale:
Rasmussen University - MDC 3 Multidimensional Care III | Comprehensive Exam
,NUR 2502 / MDC 3 Exam 1 | Rasmussen University | 2026-2027 Page 2
BRCA1 and BRCA2 are tumor suppressor genes whose normal protein products repair double-strand DNA breaks via
homologous recombination and trigger cell cycle arrest at checkpoint controls. When mutated (loss of function), DNA damage
accumulates unchecked, dramatically increasing breast, ovarian, and prostate cancer risk. This differs from oncogenes (e.g.,
HER2/neu, RAS), which promote growth when activated (gain of function), and from DNA mismatch repair genes (e.g.,
MLH1, MSH2) associated with Lynch syndrome. This distinction is essential for MDC 3 cancer genetics counseling.
Q3: When comparing benign and malignant tumors, which characteristic is unique to malignant tumors
and is the primary cause of cancer-related mortality?
A. Encapsulation within a fibrous capsule
B. Well-differentiated tissue resembling cells of origin
C. Slow, localized growth by expansion only
D. Ability to invade surrounding tissues and metastasize to distant sites via blood and lymph [CORRECT]
Correct Answer: D
Rationale:
Malignant tumors are distinguished by invasion (infiltration into adjacent tissues) and metastasis (spread to distant sites via
hematogenous, lymphatic, or seeding routes), the latter being responsible for approximately 90% of cancer deaths. Benign
tumors are typically encapsulated, well-differentiated, slow-growing, and non-invasive, remaining localized. Poor
differentiation (anaplasia) and rapid growth are additional malignant features. The capacity for metastasis through proteolytic
enzyme secretion and intravasation into vascular channels is the defining hallmark separating malignant from benign
neoplasms.
Q4: A patient is diagnosed with a breast tumor staged as T2, N1, M0. The nurse correctly interprets this
staging as:
A. Tumor in situ, no lymph node involvement, no distant metastasis
B. Tumor 2-5 cm in greatest dimension, mobile ipsilateral lymph node involvement, no distant metastasis
[CORRECT]
C. Tumor larger than 5 cm with fixed ipsilateral nodes and distant metastasis
D. Tumor less than 2 cm with no lymph node involvement but distant metastasis present
Correct Answer: B
Rationale:
In the TNM system, T2 denotes a primary tumor 2-5 cm in greatest dimension, N1 indicates mobile ipsilateral axillary lymph
node involvement, and M0 confirms absence of distant metastasis. This staging places the patient in Stage IIA, influencing
surgical, chemotherapeutic, and radiation treatment decisions. Tis would represent carcinoma in situ; T3 denotes tumors greater
than 5 cm; N2/N3 reflect more extensive or fixed nodal disease; and any M1 designation automatically classifies the cancer as
Stage IV.
Q5: A pathologist grades a tumor as "Grade 3" based on histologic examination. The nurse understands
this grade indicates:
A. Well-differentiated cells that closely resemble normal tissue and grow slowly
B. Moderately differentiated cells with intermediate aggressiveness
C. Poorly differentiated cells that barely resemble normal tissue and behave aggressively [CORRECT]
D. Tumor confined to its site of origin with no invasion
Correct Answer: C
Rationale:
Tumor grading reflects histologic differentiation: Grade 1 (well-differentiated, slow-growing, better prognosis), Grade 2
(moderately differentiated), Grade 3 (poorly differentiated, aggressive, poorer prognosis), and Grade 4
(undifferentiated/anaplastic, most aggressive). Grading is distinct from staging: grading describes how abnormal the cells
appear microscopically, while staging (TNM) describes anatomic extent of disease. Higher grades correlate with increased
Rasmussen University - MDC 3 Multidimensional Care III | Comprehensive Exam
,NUR 2502 / MDC 3 Exam 1 | Rasmussen University | 2026-2027 Page 3
mitotic activity, nuclear pleomorphism, and loss of normal tissue architecture, all of which predict more aggressive clinical
behavior.
Q6: A patient with advanced ovarian cancer has widespread tumor implants throughout the peritoneum.
The surgeon plans a procedure to remove as much tumor as possible, even though complete removal is not
achievable, to improve the response to chemotherapy. What type of surgery is this?
A. Diagnostic surgery (biopsy only)
B. Curative surgery (complete removal of all tumor)
C. Debulking surgery (cytoreductive reduction of tumor burden) [CORRECT]
D. Palliative surgery (symptom relief without tumor removal intent)
Correct Answer: C
Rationale:
Debulking (cytoreductive) surgery removes the bulk of the tumor when complete excision is impossible, reducing tumor burden to
enhance the effectiveness of adjuvant chemotherapy and radiation. This is standard in advanced ovarian cancer, where
residual disease less than 1 cm correlates with improved survival. Diagnostic surgery (biopsy) confirms diagnosis, curative
surgery aims at complete eradication of localized disease, and palliative surgery addresses symptoms (e.g., bowel obstruction
bypass, pain control) without oncologic cure intent. Reconstructive surgery restores function and appearance post-treatment.
Q7: A patient receiving external beam radiation therapy for head and neck cancer reports severe pain when
swallowing, thick saliva, and visible mouth ulcers. Which nursing intervention is the priority at this time?
A. Administer parenteral nutrition and stop oral intake entirely
B. Implement an oral care protocol with saline rinses, lidocaine mouthwash, and soft nutrient-dense foods; assess
pain control [CORRECT]
C. Recommend gum and hard candy to stimulate saliva production
D. Delay further radiation treatments until mucositis completely resolves
Correct Answer: B
Rationale:
Radiation-induced mucositis is a common side effect of head and neck irradiation, presenting with erythema, ulceration, and
dysphagia. Priority nursing care includes gentle oral hygiene (saline or baking soda rinses q2-4h, soft-bristle tooth brushing),
topical anesthetics (lidocaine viscous before meals), pain management (systemic analgesics as needed), and nutritional
modification (soft, bland, high-protein foods; avoid alcohol, tobacco, spicy/acidic foods). Complete cessation of oral intake or
treatment delays are unnecessary unless severity dictates; gum/candy may irritate ulcerated mucosa. Mucositis typically resolves
2-4 weeks post-treatment.
Q8: A patient receiving doxorubicin (Adriamycin) chemotherapy is being monitored for dose-dependent
cardiotoxicity. Which assessment finding should the nurse recognize as an early indicator of
doxorubicin-induced cardiomyopathy?
A. Peripheral neuropathy and jaw pain
B. New-onset dyspnea on exertion, fatigue, peripheral edema, and decreased ejection fraction on echocardiogram
[CORRECT]
C. Hemorrhagic cystitis with gross hematuria
D. Acute confusion and ataxia
Correct Answer: B
Rationale:
Doxorubicin (Adriamycin) is an anthracycline chemotherapeutic associated with cumulative, dose-dependent cardiotoxicity,
presenting as congestive heart failure: dyspnea on exertion, fatigue, peripheral edema, jugular venous distension, and reduced
left ventricular ejection fraction. Lifetime cumulative dose should not exceed 450-550 mg/m². Baseline and serial
echocardiograms or MUGA scans monitor cardiac function. Dexrazoxane (cardioprotectant) may be considered. Peripheral
Rasmussen University - MDC 3 Multidimensional Care III | Comprehensive Exam
, NUR 2502 / MDC 3 Exam 1 | Rasmussen University | 2026-2027 Page 4
neuropathy suggests vincristine toxicity; hemorrhagic cystitis signals cyclophosphamide/ifosfamide; confusion and ataxia
suggest high-dose methotrexate or CNS involvement.
Q9: A patient receiving vincristine chemotherapy reports new-onset numbness and tingling in the fingers
and toes, jaw pain, and difficulty buttoning shirts. The nurse identifies these as manifestations of which
chemotherapy-induced toxicity?
A. Cardiotoxicity
B. Nephrotoxicity
C. Peripheral neurotoxicity [CORRECT]
D. Hepatotoxicity
Correct Answer: C
Rationale:
Vincristine (a vinca alkaloid) causes dose-limiting peripheral neurotoxicity due to inhibition of microtubule formation in axons,
manifesting as paresthesias of extremities, loss of deep tendon reflexes, jaw pain, foot drop, constipation (autonomic
neuropathy), and impaired fine motor skills. Symptoms are typically reversible after dose reduction or discontinuation. Nurses
should assess for falls, constipation, and safe ambulation. Cardiotoxicity is associated with anthracyclines; nephrotoxicity with
cisplatin; hepatotoxicity with methotrexate and asparaginase. Nursing care includes safety measures, bowel regimens, and
neurovascular monitoring.
Q10: A patient receiving cyclophosphamide chemotherapy is at risk for hemorrhagic cystitis. Which
prophylactic intervention should the nurse anticipate administering to prevent this complication?
A. Restrict fluids to 1 L per day to reduce bladder filling
B. Administer mesna (2-mercaptoethane sulfonate) and maintain aggressive hydration with IV fluids
[CORRECT]
C. Insert an indwelling Foley catheter for the duration of treatment
D. Administer allopurinol 300 mg orally daily
Correct Answer: B
Rationale:
Cyclophosphamide and ifosfamide metabolites (particularly acrolein) accumulate in the bladder and cause urothelial damage
leading to hemorrhagic cystitis. Prophylaxis includes aggressive IV hydration (3 L/day minimum) to dilute urinary metabolites
and administration of mesna, which binds acrolein in the urine and detoxifies it. Allopurinol is used for tumor lysis syndrome
prophylaxis (not bladder protection). Fluid restriction would worsen the problem. Foley catheters are not routinely used
prophylactically. Urine should be monitored for hematuria; gross hematuria requires immediate provider notification.
Q11: A 32-year-old patient with newly diagnosed acute lymphoblastic leukemia began chemotherapy 48
hours ago. Lab results reveal potassium 6.8 mEq/L, uric acid 18 mg/dL, phosphate 9.2 mg/dL, and calcium
6.1 mg/dL. The nurse recognizes these findings as tumor lysis syndrome (TLS). What is the priority nursing
intervention?
A. Administer oral allopurinol, begin IV hydration with 0.9% normal saline at 3 L/m²/day, and prepare to give
rasburicase [CORRECT]
B. Restrict all IV fluids to prevent fluid overload and administer calcium gluconate immediately
C. Administer potassium chloride to correct hypokalemia and discontinue chemotherapy
D. Give spironolactone to manage hyperkalemia and limit patient movement
Correct Answer: A
Rationale:
Tumor lysis syndrome occurs when rapid tumor cell breakdown releases intracellular contents (potassium, phosphate, uric acid
from nucleic acid catabolism), leading to hyperkalemia, hyperphosphatemia, hyperuricemia, and secondary hypocalcemia.
Renal failure and lethal cardiac dysrhythmias may result. Priority management: aggressive IV hydration (3 L/m²/day) to
Rasmussen University - MDC 3 Multidimensional Care III | Comprehensive Exam
Exam 1 - NUR 2502 / NUR2502
Multidimensional Care III (MDC 3)
Latest | Rasmussen University
Total Questions: 75
Cognitive Levels: 25% Recall / 55% Application / 20% Analysis
Format: Multiple Choice (4 options, 1 correct)
Question Style: 70% Scenario / 20% Recall / 10% Clinical Judgment
Sections: 7 (Oncology, Hematologic, Immunologic, MSK, Integumentary, Neuro, Integrated)
Aligned With: Rasmussen MDC 3 NUR 2502 Curriculum Blueprint
INSTRUCTIONS: This comprehensive examination assesses competency across seven core domains of Multidimensional Care III.
Each question includes the correct answer and a detailed clinical rationale grounded in MDC 3 nursing competencies,
evidence-based practice, and Rasmussen University 2026-2027 curriculum standards. Use the rationales to reinforce
pathophysiologic reasoning and prioritization skills.
Section 1: Oncology Nursing (Cancer Pathophysiology, Staging, Treatment
Modalities, & Nursing Care) (Q1-Q15)
Q1: A 58-year-old female patient asks the nurse to explain how a normal cell transforms into a malignant
cell. The nurse correctly describes the three sequential phases of carcinogenesis in which order?
A. Progression, initiation, promotion
B. Initiation, promotion, progression [CORRECT]
C. Promotion, progression, initiation
D. Initiation, progression, promotion
Correct Answer: B
Rationale:
Carcinogenesis proceeds through initiation (exposure to carcinogen causing irreversible DNA mutation), promotion (reversible
clonal expansion of initiated cells triggered by promoters like hormones or chronic inflammation), and progression (irreversible
conversion to malignant phenotype with invasion and metastasis). This sequence reflects the multistep nature of cancer
development and explains why risk reduction at any phase can interrupt malignant transformation. Reversing the order
misrepresents the biologic cascade central to MDC 3 oncology pathophysiology.
Q2: A patient with a strong family history of breast and ovarian cancer tests positive for a mutation in the
BRCA1 gene. The nurse understands that BRCA1 is classified as which type of gene, and what is its normal
function?
A. Oncogene; stimulates cell division when mutated
B. DNA repair gene; repairs mismatches in base pairing
C. Tumor suppressor gene; inhibits uncontrolled cell growth by repairing DNA damage and regulating cell cycle
arrest [CORRECT]
D. Promoter gene; initiates transcription of growth factors
Correct Answer: C
Rationale:
Rasmussen University - MDC 3 Multidimensional Care III | Comprehensive Exam
,NUR 2502 / MDC 3 Exam 1 | Rasmussen University | 2026-2027 Page 2
BRCA1 and BRCA2 are tumor suppressor genes whose normal protein products repair double-strand DNA breaks via
homologous recombination and trigger cell cycle arrest at checkpoint controls. When mutated (loss of function), DNA damage
accumulates unchecked, dramatically increasing breast, ovarian, and prostate cancer risk. This differs from oncogenes (e.g.,
HER2/neu, RAS), which promote growth when activated (gain of function), and from DNA mismatch repair genes (e.g.,
MLH1, MSH2) associated with Lynch syndrome. This distinction is essential for MDC 3 cancer genetics counseling.
Q3: When comparing benign and malignant tumors, which characteristic is unique to malignant tumors
and is the primary cause of cancer-related mortality?
A. Encapsulation within a fibrous capsule
B. Well-differentiated tissue resembling cells of origin
C. Slow, localized growth by expansion only
D. Ability to invade surrounding tissues and metastasize to distant sites via blood and lymph [CORRECT]
Correct Answer: D
Rationale:
Malignant tumors are distinguished by invasion (infiltration into adjacent tissues) and metastasis (spread to distant sites via
hematogenous, lymphatic, or seeding routes), the latter being responsible for approximately 90% of cancer deaths. Benign
tumors are typically encapsulated, well-differentiated, slow-growing, and non-invasive, remaining localized. Poor
differentiation (anaplasia) and rapid growth are additional malignant features. The capacity for metastasis through proteolytic
enzyme secretion and intravasation into vascular channels is the defining hallmark separating malignant from benign
neoplasms.
Q4: A patient is diagnosed with a breast tumor staged as T2, N1, M0. The nurse correctly interprets this
staging as:
A. Tumor in situ, no lymph node involvement, no distant metastasis
B. Tumor 2-5 cm in greatest dimension, mobile ipsilateral lymph node involvement, no distant metastasis
[CORRECT]
C. Tumor larger than 5 cm with fixed ipsilateral nodes and distant metastasis
D. Tumor less than 2 cm with no lymph node involvement but distant metastasis present
Correct Answer: B
Rationale:
In the TNM system, T2 denotes a primary tumor 2-5 cm in greatest dimension, N1 indicates mobile ipsilateral axillary lymph
node involvement, and M0 confirms absence of distant metastasis. This staging places the patient in Stage IIA, influencing
surgical, chemotherapeutic, and radiation treatment decisions. Tis would represent carcinoma in situ; T3 denotes tumors greater
than 5 cm; N2/N3 reflect more extensive or fixed nodal disease; and any M1 designation automatically classifies the cancer as
Stage IV.
Q5: A pathologist grades a tumor as "Grade 3" based on histologic examination. The nurse understands
this grade indicates:
A. Well-differentiated cells that closely resemble normal tissue and grow slowly
B. Moderately differentiated cells with intermediate aggressiveness
C. Poorly differentiated cells that barely resemble normal tissue and behave aggressively [CORRECT]
D. Tumor confined to its site of origin with no invasion
Correct Answer: C
Rationale:
Tumor grading reflects histologic differentiation: Grade 1 (well-differentiated, slow-growing, better prognosis), Grade 2
(moderately differentiated), Grade 3 (poorly differentiated, aggressive, poorer prognosis), and Grade 4
(undifferentiated/anaplastic, most aggressive). Grading is distinct from staging: grading describes how abnormal the cells
appear microscopically, while staging (TNM) describes anatomic extent of disease. Higher grades correlate with increased
Rasmussen University - MDC 3 Multidimensional Care III | Comprehensive Exam
,NUR 2502 / MDC 3 Exam 1 | Rasmussen University | 2026-2027 Page 3
mitotic activity, nuclear pleomorphism, and loss of normal tissue architecture, all of which predict more aggressive clinical
behavior.
Q6: A patient with advanced ovarian cancer has widespread tumor implants throughout the peritoneum.
The surgeon plans a procedure to remove as much tumor as possible, even though complete removal is not
achievable, to improve the response to chemotherapy. What type of surgery is this?
A. Diagnostic surgery (biopsy only)
B. Curative surgery (complete removal of all tumor)
C. Debulking surgery (cytoreductive reduction of tumor burden) [CORRECT]
D. Palliative surgery (symptom relief without tumor removal intent)
Correct Answer: C
Rationale:
Debulking (cytoreductive) surgery removes the bulk of the tumor when complete excision is impossible, reducing tumor burden to
enhance the effectiveness of adjuvant chemotherapy and radiation. This is standard in advanced ovarian cancer, where
residual disease less than 1 cm correlates with improved survival. Diagnostic surgery (biopsy) confirms diagnosis, curative
surgery aims at complete eradication of localized disease, and palliative surgery addresses symptoms (e.g., bowel obstruction
bypass, pain control) without oncologic cure intent. Reconstructive surgery restores function and appearance post-treatment.
Q7: A patient receiving external beam radiation therapy for head and neck cancer reports severe pain when
swallowing, thick saliva, and visible mouth ulcers. Which nursing intervention is the priority at this time?
A. Administer parenteral nutrition and stop oral intake entirely
B. Implement an oral care protocol with saline rinses, lidocaine mouthwash, and soft nutrient-dense foods; assess
pain control [CORRECT]
C. Recommend gum and hard candy to stimulate saliva production
D. Delay further radiation treatments until mucositis completely resolves
Correct Answer: B
Rationale:
Radiation-induced mucositis is a common side effect of head and neck irradiation, presenting with erythema, ulceration, and
dysphagia. Priority nursing care includes gentle oral hygiene (saline or baking soda rinses q2-4h, soft-bristle tooth brushing),
topical anesthetics (lidocaine viscous before meals), pain management (systemic analgesics as needed), and nutritional
modification (soft, bland, high-protein foods; avoid alcohol, tobacco, spicy/acidic foods). Complete cessation of oral intake or
treatment delays are unnecessary unless severity dictates; gum/candy may irritate ulcerated mucosa. Mucositis typically resolves
2-4 weeks post-treatment.
Q8: A patient receiving doxorubicin (Adriamycin) chemotherapy is being monitored for dose-dependent
cardiotoxicity. Which assessment finding should the nurse recognize as an early indicator of
doxorubicin-induced cardiomyopathy?
A. Peripheral neuropathy and jaw pain
B. New-onset dyspnea on exertion, fatigue, peripheral edema, and decreased ejection fraction on echocardiogram
[CORRECT]
C. Hemorrhagic cystitis with gross hematuria
D. Acute confusion and ataxia
Correct Answer: B
Rationale:
Doxorubicin (Adriamycin) is an anthracycline chemotherapeutic associated with cumulative, dose-dependent cardiotoxicity,
presenting as congestive heart failure: dyspnea on exertion, fatigue, peripheral edema, jugular venous distension, and reduced
left ventricular ejection fraction. Lifetime cumulative dose should not exceed 450-550 mg/m². Baseline and serial
echocardiograms or MUGA scans monitor cardiac function. Dexrazoxane (cardioprotectant) may be considered. Peripheral
Rasmussen University - MDC 3 Multidimensional Care III | Comprehensive Exam
, NUR 2502 / MDC 3 Exam 1 | Rasmussen University | 2026-2027 Page 4
neuropathy suggests vincristine toxicity; hemorrhagic cystitis signals cyclophosphamide/ifosfamide; confusion and ataxia
suggest high-dose methotrexate or CNS involvement.
Q9: A patient receiving vincristine chemotherapy reports new-onset numbness and tingling in the fingers
and toes, jaw pain, and difficulty buttoning shirts. The nurse identifies these as manifestations of which
chemotherapy-induced toxicity?
A. Cardiotoxicity
B. Nephrotoxicity
C. Peripheral neurotoxicity [CORRECT]
D. Hepatotoxicity
Correct Answer: C
Rationale:
Vincristine (a vinca alkaloid) causes dose-limiting peripheral neurotoxicity due to inhibition of microtubule formation in axons,
manifesting as paresthesias of extremities, loss of deep tendon reflexes, jaw pain, foot drop, constipation (autonomic
neuropathy), and impaired fine motor skills. Symptoms are typically reversible after dose reduction or discontinuation. Nurses
should assess for falls, constipation, and safe ambulation. Cardiotoxicity is associated with anthracyclines; nephrotoxicity with
cisplatin; hepatotoxicity with methotrexate and asparaginase. Nursing care includes safety measures, bowel regimens, and
neurovascular monitoring.
Q10: A patient receiving cyclophosphamide chemotherapy is at risk for hemorrhagic cystitis. Which
prophylactic intervention should the nurse anticipate administering to prevent this complication?
A. Restrict fluids to 1 L per day to reduce bladder filling
B. Administer mesna (2-mercaptoethane sulfonate) and maintain aggressive hydration with IV fluids
[CORRECT]
C. Insert an indwelling Foley catheter for the duration of treatment
D. Administer allopurinol 300 mg orally daily
Correct Answer: B
Rationale:
Cyclophosphamide and ifosfamide metabolites (particularly acrolein) accumulate in the bladder and cause urothelial damage
leading to hemorrhagic cystitis. Prophylaxis includes aggressive IV hydration (3 L/day minimum) to dilute urinary metabolites
and administration of mesna, which binds acrolein in the urine and detoxifies it. Allopurinol is used for tumor lysis syndrome
prophylaxis (not bladder protection). Fluid restriction would worsen the problem. Foley catheters are not routinely used
prophylactically. Urine should be monitored for hematuria; gross hematuria requires immediate provider notification.
Q11: A 32-year-old patient with newly diagnosed acute lymphoblastic leukemia began chemotherapy 48
hours ago. Lab results reveal potassium 6.8 mEq/L, uric acid 18 mg/dL, phosphate 9.2 mg/dL, and calcium
6.1 mg/dL. The nurse recognizes these findings as tumor lysis syndrome (TLS). What is the priority nursing
intervention?
A. Administer oral allopurinol, begin IV hydration with 0.9% normal saline at 3 L/m²/day, and prepare to give
rasburicase [CORRECT]
B. Restrict all IV fluids to prevent fluid overload and administer calcium gluconate immediately
C. Administer potassium chloride to correct hypokalemia and discontinue chemotherapy
D. Give spironolactone to manage hyperkalemia and limit patient movement
Correct Answer: A
Rationale:
Tumor lysis syndrome occurs when rapid tumor cell breakdown releases intracellular contents (potassium, phosphate, uric acid
from nucleic acid catabolism), leading to hyperkalemia, hyperphosphatemia, hyperuricemia, and secondary hypocalcemia.
Renal failure and lethal cardiac dysrhythmias may result. Priority management: aggressive IV hydration (3 L/m²/day) to
Rasmussen University - MDC 3 Multidimensional Care III | Comprehensive Exam
