NUR 2755 MDC4 Final Exam| Questions with 100% Correct
Answers | Verified | Latest Update -Rasmussen College
1. A 56-year-old client comes to the triage area with left-sided chest pain, diaphoresis, and dizziness,
with an oxygen saturation of 88% on room air. What is the priority action?
A. Notify the emergency department physician.
B. Establish IV access.
C. Administer oxygen via nasal cannula.
D. Place the client on continuous electrocardiographic monitoring.
2. The nurse is evaluating pre-admission laboratory studies, including a complete blood count,
coagulation studies, and electrolytes and creatinine levels. Which of the following laboratory results
should be reported to the surgeon's office knowing that it could cause the surgery to be postponed?
A. Serum creatinine, 0.8 mg/dL.
B. Hemoglobin, 14.8 g/dL.
C. Sodium, 141 mEq/L.
D. Platelets, 40,000/mm3.
3. A client is receiving warfarin after pulmonary embolisms (PE). The nurse evaluates the lab results and
notifies the physician that the client's warfarin level is therapeutic when which of the following is
reported?
A. International Normalized Ratio (INR) 1.1.
B. Partial thromboplastin time (PTT) 24 seconds.
C. International normalized ratio (INR) 2.8.
D. Prothrombin time (PT) 14 seconds.
4. A nurse is caring for a client suspected of having heatstroke. Which findings are consistent with this
diagnosis? Select all that apply.
A. Tachypnea.
B. Decreased urinary output.
,C. Hallucinations.
D. Bradycardia.
E. Dysrhythmias.
5. A nurse prepares to administer intravenous pantoprazole to a client who has a new burn injury. The
client asks "Why am I taking this medication?" How should the nurse respond?
A. Pantoprazole protects the kidneys from damage caused by dehydration.
B. It improves fluid retention, which helps prevent hypovolemic shock.
C. It helps prevent stomach ulcers, which are common in burns.
D. Pantoprozaloe stimulates intestinal movement so you can eat more.
6. A client's blood pressure reading is 104/50 mm Hg. After determining the mean arterial pressure, the
nurse understands the client is at risk for which of the following complications?
A. Increase in organ perfusion.
B. Increased stroke volume.
C. Decrease in cardiac output.
D. Rebound hypertension.
7. The client is admitted to the hospital with a diagnosis of Guillian-Barre syndrome. During the nursing
admission interview, the nurse inquires if the client has a history of which of the following?
A. Meningitis during the last five years.
B. Respiratory or gastrointestinal infection during the previous month.
C. Seizures or trauma to the brain.
D. Back injury or trauma to the spinal cord.
8. Following a stroke, a client has dysphagia and left-side paralysis. Which feeding technique will be most
helpful at this time?
, A. Feed the client a soft diet from a spoon into the left side of the mouth.
B. Position the client with the bed at a 30 degree angle.
C. Offer solid foods from the unaffected side of the mouth.
D. Encourage sipping diluted liquid meal supplements from a straw.
9. A client with a chest injury has suffered a flail chest. A nurse assesses the client for which most
distinctive sign of flail chest?
A. Cyanosis.
B. Hypertension.
C. Dyspnea, especially on exhalation.
D. Paradoxical chest movement.
10. A nurse is triaging clients in the emergency department, which client would the nurse classify as
urgent?
A. A 79-year-old with a temperature of 104 F (40 C).
B. A 50-year-old with chest trauma and absent breath sounds.
C. A 44-year old with chest pain and diaphoresis.
D. A 62-year old with a simple fracture of the left arm.
11. A nurse is reviewing the health records of six clients. Which of the following clients are at risk for
developing acute respiratory distress syndrome? (Select all that apply)
A. A client who experienced sepsis.
B. A client who experienced a stroke with aspiration.
C. A client who experienced an inhalation burn.
D. A client who experienced a near-drowning incident.
E. A client who experienced blunt force trauma.
Answers | Verified | Latest Update -Rasmussen College
1. A 56-year-old client comes to the triage area with left-sided chest pain, diaphoresis, and dizziness,
with an oxygen saturation of 88% on room air. What is the priority action?
A. Notify the emergency department physician.
B. Establish IV access.
C. Administer oxygen via nasal cannula.
D. Place the client on continuous electrocardiographic monitoring.
2. The nurse is evaluating pre-admission laboratory studies, including a complete blood count,
coagulation studies, and electrolytes and creatinine levels. Which of the following laboratory results
should be reported to the surgeon's office knowing that it could cause the surgery to be postponed?
A. Serum creatinine, 0.8 mg/dL.
B. Hemoglobin, 14.8 g/dL.
C. Sodium, 141 mEq/L.
D. Platelets, 40,000/mm3.
3. A client is receiving warfarin after pulmonary embolisms (PE). The nurse evaluates the lab results and
notifies the physician that the client's warfarin level is therapeutic when which of the following is
reported?
A. International Normalized Ratio (INR) 1.1.
B. Partial thromboplastin time (PTT) 24 seconds.
C. International normalized ratio (INR) 2.8.
D. Prothrombin time (PT) 14 seconds.
4. A nurse is caring for a client suspected of having heatstroke. Which findings are consistent with this
diagnosis? Select all that apply.
A. Tachypnea.
B. Decreased urinary output.
,C. Hallucinations.
D. Bradycardia.
E. Dysrhythmias.
5. A nurse prepares to administer intravenous pantoprazole to a client who has a new burn injury. The
client asks "Why am I taking this medication?" How should the nurse respond?
A. Pantoprazole protects the kidneys from damage caused by dehydration.
B. It improves fluid retention, which helps prevent hypovolemic shock.
C. It helps prevent stomach ulcers, which are common in burns.
D. Pantoprozaloe stimulates intestinal movement so you can eat more.
6. A client's blood pressure reading is 104/50 mm Hg. After determining the mean arterial pressure, the
nurse understands the client is at risk for which of the following complications?
A. Increase in organ perfusion.
B. Increased stroke volume.
C. Decrease in cardiac output.
D. Rebound hypertension.
7. The client is admitted to the hospital with a diagnosis of Guillian-Barre syndrome. During the nursing
admission interview, the nurse inquires if the client has a history of which of the following?
A. Meningitis during the last five years.
B. Respiratory or gastrointestinal infection during the previous month.
C. Seizures or trauma to the brain.
D. Back injury or trauma to the spinal cord.
8. Following a stroke, a client has dysphagia and left-side paralysis. Which feeding technique will be most
helpful at this time?
, A. Feed the client a soft diet from a spoon into the left side of the mouth.
B. Position the client with the bed at a 30 degree angle.
C. Offer solid foods from the unaffected side of the mouth.
D. Encourage sipping diluted liquid meal supplements from a straw.
9. A client with a chest injury has suffered a flail chest. A nurse assesses the client for which most
distinctive sign of flail chest?
A. Cyanosis.
B. Hypertension.
C. Dyspnea, especially on exhalation.
D. Paradoxical chest movement.
10. A nurse is triaging clients in the emergency department, which client would the nurse classify as
urgent?
A. A 79-year-old with a temperature of 104 F (40 C).
B. A 50-year-old with chest trauma and absent breath sounds.
C. A 44-year old with chest pain and diaphoresis.
D. A 62-year old with a simple fracture of the left arm.
11. A nurse is reviewing the health records of six clients. Which of the following clients are at risk for
developing acute respiratory distress syndrome? (Select all that apply)
A. A client who experienced sepsis.
B. A client who experienced a stroke with aspiration.
C. A client who experienced an inhalation burn.
D. A client who experienced a near-drowning incident.
E. A client who experienced blunt force trauma.
