,NUR 2502 / NUR 2502 Exam 1
Multidimensional Care III (MDC III) |
Rasmussen University | 2026/2027 Exam Prep
+ Clinical Judgment Q&A
Q1. A client receiving chemotherapy for breast cancer has a white blood cell count of
1,800/mm³ and a temperature of 100.8°F. Which action should the nurse take first?
A. Administer acetaminophen for fever
B. Obtain blood cultures and notify the provider
C. Encourage the client to increase oral fluids
D. Place the client in a private room and implement neutropenic precautions
Correct Answer: B. Obtain blood cultures and notify the provider
Rationale: The client has neutropenia (absolute neutrophil count below 1,500/mm³) and a
fever, which indicates possible neutropenic sepsis, a life-threatening emergency. The priority
is to obtain blood cultures before administering antibiotics and to notify the provider
immediately. Administering acetaminophen masks the fever and delays diagnosis.
Encouraging fluids is supportive but not the priority. Placing the client in a private room and
implementing neutropenic precautions is appropriate but does not take precedence over
obtaining cultures and notifying the provider. The nurse should also monitor for signs of
infection and administer antibiotics as prescribed.
Key Takeaway: Fever in a neutropenic client requires immediate blood cultures and provider
notification for suspected sepsis.
Q2. A client with syndrome of inappropriate antidiuretic hormone has a serum sodium level
of 118 mEq/L and is confused. Which action should the nurse take first?
A. Administer 0.9% sodium chloride IV bolus
B. Restrict fluid intake
C. Monitor neurologic status and seizure precautions
D. Administer 3% sodium chloride IV as prescribed
,Correct Answer: C. Monitor neurologic status and seizure precautions
Rationale: Severe hyponatremia (serum sodium below 120 mEq/L) can cause cerebral edema,
seizures, and coma. The priority is to monitor neurologic status and implement seizure
precautions. Administering 0.9% sodium chloride is not appropriate for SIADH because it can
worsen hyponatremia. Fluid restriction is a treatment for SIADH but is not the first action
during acute neurologic deterioration. Hypertonic saline (3%) may be prescribed but requires
careful monitoring and is not the initial nursing action. The nurse should also monitor serum
sodium levels closely.
Key Takeaway: Severe hyponatremia requires immediate neurologic monitoring and seizure
precautions.
Q3. A client with a spinal cord injury at T5 develops a severe headache, blood pressure
220/118 mm Hg, and heart rate 48 beats/min. Which action should the nurse take first?
A. Administer antihypertensive medication
B. Elevate the head of the bed to 90 degrees
C. Insert a urinary catheter
D. Perform a rectal examination
Correct Answer: B. Elevate the head of the bed to 90 degrees
Rationale: Autonomic dysreflexia is a life-threatening emergency in clients with spinal cord
injuries at or above T6. It is triggered by a noxious stimulus below the level of injury, most
commonly a distended bladder. The first action is to elevate the head of the bed to 90 degrees
to reduce intracranial pressure and lower blood pressure. Then the nurse should identify and
remove the trigger. Antihypertensive medication may be needed if blood pressure remains
elevated. Rectal examination can worsen the condition.
Key Takeaway: Elevate the head of the bed first for autonomic dysreflexia, then remove the
trigger.
Q4. A client with cirrhosis has a serum ammonia level of 210 mcg/dL and increasing
confusion. Which medication should the nurse anticipate administering?
A. Lactulose
B. Furosemide
, C. Spironolactone
D. Propranolol
Correct Answer: A. Lactulose
Rationale: Hepatic encephalopathy occurs when the damaged liver cannot convert ammonia
to urea. Lactulose is a laxative that traps ammonia in the gut and promotes its excretion in the
stool, reducing serum ammonia levels. Furosemide and spironolactone are diuretics used for
ascites. Propranolol is used for portal hypertension prophylaxis. The nurse should also
monitor for improvement in mental status and ammonia levels.
Key Takeaway: Lactulose reduces ammonia levels in hepatic encephalopathy.
Q5. A client with Graves disease is admitted with a heart rate of 152 beats/min, temperature
of 104.2°F, and severe agitation. Which medication should the nurse anticipate administering
first?
A. Methimazole
B. Propranolol
C. Levothyroxine
D. Radioactive iodine
Correct Answer: B. Propranolol
Rationale: This client is experiencing thyroid storm, a life-threatening exacerbation of
hyperthyroidism. Propranolol, a beta-blocker, is administered first to control the sympathetic
effects of excess thyroid hormone, including tachycardia, agitation, and hyperthermia.
Methimazole and radioactive iodine are used for long-term management of hyperthyroidism.
Levothyroxine is used for hypothyroidism. The nurse should also administer supportive care
and monitor for cardiac dysrhythmias.
Key Takeaway: Beta-blockers such as propranolol are first-line for thyroid storm to control
sympathetic symptoms.
Q6. A client with a perforated peptic ulcer presents with sudden severe abdominal pain, a
rigid board-like abdomen, and absent bowel sounds. Which action should the nurse take first?
A. Administer a PRN antacid
Multidimensional Care III (MDC III) |
Rasmussen University | 2026/2027 Exam Prep
+ Clinical Judgment Q&A
Q1. A client receiving chemotherapy for breast cancer has a white blood cell count of
1,800/mm³ and a temperature of 100.8°F. Which action should the nurse take first?
A. Administer acetaminophen for fever
B. Obtain blood cultures and notify the provider
C. Encourage the client to increase oral fluids
D. Place the client in a private room and implement neutropenic precautions
Correct Answer: B. Obtain blood cultures and notify the provider
Rationale: The client has neutropenia (absolute neutrophil count below 1,500/mm³) and a
fever, which indicates possible neutropenic sepsis, a life-threatening emergency. The priority
is to obtain blood cultures before administering antibiotics and to notify the provider
immediately. Administering acetaminophen masks the fever and delays diagnosis.
Encouraging fluids is supportive but not the priority. Placing the client in a private room and
implementing neutropenic precautions is appropriate but does not take precedence over
obtaining cultures and notifying the provider. The nurse should also monitor for signs of
infection and administer antibiotics as prescribed.
Key Takeaway: Fever in a neutropenic client requires immediate blood cultures and provider
notification for suspected sepsis.
Q2. A client with syndrome of inappropriate antidiuretic hormone has a serum sodium level
of 118 mEq/L and is confused. Which action should the nurse take first?
A. Administer 0.9% sodium chloride IV bolus
B. Restrict fluid intake
C. Monitor neurologic status and seizure precautions
D. Administer 3% sodium chloride IV as prescribed
,Correct Answer: C. Monitor neurologic status and seizure precautions
Rationale: Severe hyponatremia (serum sodium below 120 mEq/L) can cause cerebral edema,
seizures, and coma. The priority is to monitor neurologic status and implement seizure
precautions. Administering 0.9% sodium chloride is not appropriate for SIADH because it can
worsen hyponatremia. Fluid restriction is a treatment for SIADH but is not the first action
during acute neurologic deterioration. Hypertonic saline (3%) may be prescribed but requires
careful monitoring and is not the initial nursing action. The nurse should also monitor serum
sodium levels closely.
Key Takeaway: Severe hyponatremia requires immediate neurologic monitoring and seizure
precautions.
Q3. A client with a spinal cord injury at T5 develops a severe headache, blood pressure
220/118 mm Hg, and heart rate 48 beats/min. Which action should the nurse take first?
A. Administer antihypertensive medication
B. Elevate the head of the bed to 90 degrees
C. Insert a urinary catheter
D. Perform a rectal examination
Correct Answer: B. Elevate the head of the bed to 90 degrees
Rationale: Autonomic dysreflexia is a life-threatening emergency in clients with spinal cord
injuries at or above T6. It is triggered by a noxious stimulus below the level of injury, most
commonly a distended bladder. The first action is to elevate the head of the bed to 90 degrees
to reduce intracranial pressure and lower blood pressure. Then the nurse should identify and
remove the trigger. Antihypertensive medication may be needed if blood pressure remains
elevated. Rectal examination can worsen the condition.
Key Takeaway: Elevate the head of the bed first for autonomic dysreflexia, then remove the
trigger.
Q4. A client with cirrhosis has a serum ammonia level of 210 mcg/dL and increasing
confusion. Which medication should the nurse anticipate administering?
A. Lactulose
B. Furosemide
, C. Spironolactone
D. Propranolol
Correct Answer: A. Lactulose
Rationale: Hepatic encephalopathy occurs when the damaged liver cannot convert ammonia
to urea. Lactulose is a laxative that traps ammonia in the gut and promotes its excretion in the
stool, reducing serum ammonia levels. Furosemide and spironolactone are diuretics used for
ascites. Propranolol is used for portal hypertension prophylaxis. The nurse should also
monitor for improvement in mental status and ammonia levels.
Key Takeaway: Lactulose reduces ammonia levels in hepatic encephalopathy.
Q5. A client with Graves disease is admitted with a heart rate of 152 beats/min, temperature
of 104.2°F, and severe agitation. Which medication should the nurse anticipate administering
first?
A. Methimazole
B. Propranolol
C. Levothyroxine
D. Radioactive iodine
Correct Answer: B. Propranolol
Rationale: This client is experiencing thyroid storm, a life-threatening exacerbation of
hyperthyroidism. Propranolol, a beta-blocker, is administered first to control the sympathetic
effects of excess thyroid hormone, including tachycardia, agitation, and hyperthermia.
Methimazole and radioactive iodine are used for long-term management of hyperthyroidism.
Levothyroxine is used for hypothyroidism. The nurse should also administer supportive care
and monitor for cardiac dysrhythmias.
Key Takeaway: Beta-blockers such as propranolol are first-line for thyroid storm to control
sympathetic symptoms.
Q6. A client with a perforated peptic ulcer presents with sudden severe abdominal pain, a
rigid board-like abdomen, and absent bowel sounds. Which action should the nurse take first?
A. Administer a PRN antacid
