MDC4 Exam Questions with 100% Verified
Correct Answers 2024/2025
The client recovering from a head injury is arousable and participating in care. Which of the following
demonstrates effective client teaching in preventing intracranial pressure? - Correct Answer Maintain
an elevated head of the bed to 30 degrees
The spouse of a 67-year-old male patient with early-stage Alzheimer's disease (AD) tells the nurse, "I
am exhausted from worrying all the time. I do not know what to do." Which actions are best for the
nurse to take next (select all that apply)? - Correct Answer Offer ideas for ways to distract or redirect
the patient.
Teach the spouse about adult day care as a possible respite.
Ask the spouse what she knows and has considered about dementia care options.
The high-pressure alarm sounds on a ventilator. AfterAfter looking over the client and the ventilator,
the nurse takes what action next? - Correct Answer Suctions the client to remove excess excretions
The client has returned to the surgical unit from the post-anesthesia unit. The client's respirations are
rapid and shallow, the pulse is 120 beats/min, and the blood pressure is 88/52 the client's LOC is
declining. what should the nurse do first? - Correct Answer Call the rapid response team/ Medical
emergency team
The nurse has instructed the family of a client who has had a stroke and has homonymous
hemianopsia about measures to help the client overcome the deficit. the nurse determines the
understanding of the education when which correct statement is made? - Correct Answer we should
remind the client to turn the head to scan the lost visual field.
The client scheduled for surgery is confused and shows signs of dementia. There is no advance
directive of file designating a pow of attorney for health care. The nurse should ask which person to
sign the consent for the client. - Correct Answer Spouse
The nurse assesses a client with drainage from the nose following a basilar skull fracture. Which
evaluation by the nurse helps positively identify the drainage as cerebrospinal fluid? - Correct Answer
The fluid separates into concentric rigs and tests positive for glucose
A client receives fluid resuscitation per the parkland formula after a severe burn and continues to
have urine output ranging from 20-25ml/hr. After the health care provider checks the client, which
order does the nurse question? - Correct Answer Administer furosemide 40mg iv push
, A nurse assesses a client with a long history of seizure disorder. Which manifestation does the nurse
understand is a typical reaction to long-term phenytoin sodium therapy? - Correct Answer Excessive
growth of gum tissue
A client with a head injury regains consciousness after several days. When the client first awakes
what should the nurse say to the client - Correct Answer You are in the hospital. You were in an
accident and unconscious
On a hot, humid day. A client arrives at the emergency department presenting with confusion,
lethargy, and the following vitals temperature 104.1 degrees F, pulse, 132 beats/min, respirations 26
breaths/min, and blood pressure 106/66. what is the most appropriate intervention for this client? -
Correct Answer Start an intervenous line and infuse 0.9% saline solution
A nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse is
interpreted as a normal finding at the surgical site? - Correct Answer Serous drainage
A client with hypotension and an elevated temperature after working outside on a hot day is treated
in the emergency department. The nurse determines that discharge teaching has been effective
when the client makes which statement? - Correct Answer I should drink electrolyte sports drinks
when working outside in the hot weather
A triage officer is discussing mass casualty triage during a tabletop disaster drill. which statement
indicates further education is needed - Correct Answer Client is the urgent category would include
shock and airway obstruction
The nurse is caring for the client, who begins to experience seizure activity while in bed. Which of the
following actions by the nurse would be contraindicated? - Correct Answer Restraining the client's
limbs
A client is on intravenous heparin to treat a pulmonary embolism. The client reports bleeding gums
and PTT was 120 seconds - Correct Answer Stop the heparin and notify the healthcare provider
An emergency department charge nurse notes an increase in sick calls and bickering among the staff
after a week with multiple trauma incidents. which actions would the nurse take? - Correct Answer
Arrange for critical incident stress debriefing
Correct Answers 2024/2025
The client recovering from a head injury is arousable and participating in care. Which of the following
demonstrates effective client teaching in preventing intracranial pressure? - Correct Answer Maintain
an elevated head of the bed to 30 degrees
The spouse of a 67-year-old male patient with early-stage Alzheimer's disease (AD) tells the nurse, "I
am exhausted from worrying all the time. I do not know what to do." Which actions are best for the
nurse to take next (select all that apply)? - Correct Answer Offer ideas for ways to distract or redirect
the patient.
Teach the spouse about adult day care as a possible respite.
Ask the spouse what she knows and has considered about dementia care options.
The high-pressure alarm sounds on a ventilator. AfterAfter looking over the client and the ventilator,
the nurse takes what action next? - Correct Answer Suctions the client to remove excess excretions
The client has returned to the surgical unit from the post-anesthesia unit. The client's respirations are
rapid and shallow, the pulse is 120 beats/min, and the blood pressure is 88/52 the client's LOC is
declining. what should the nurse do first? - Correct Answer Call the rapid response team/ Medical
emergency team
The nurse has instructed the family of a client who has had a stroke and has homonymous
hemianopsia about measures to help the client overcome the deficit. the nurse determines the
understanding of the education when which correct statement is made? - Correct Answer we should
remind the client to turn the head to scan the lost visual field.
The client scheduled for surgery is confused and shows signs of dementia. There is no advance
directive of file designating a pow of attorney for health care. The nurse should ask which person to
sign the consent for the client. - Correct Answer Spouse
The nurse assesses a client with drainage from the nose following a basilar skull fracture. Which
evaluation by the nurse helps positively identify the drainage as cerebrospinal fluid? - Correct Answer
The fluid separates into concentric rigs and tests positive for glucose
A client receives fluid resuscitation per the parkland formula after a severe burn and continues to
have urine output ranging from 20-25ml/hr. After the health care provider checks the client, which
order does the nurse question? - Correct Answer Administer furosemide 40mg iv push
, A nurse assesses a client with a long history of seizure disorder. Which manifestation does the nurse
understand is a typical reaction to long-term phenytoin sodium therapy? - Correct Answer Excessive
growth of gum tissue
A client with a head injury regains consciousness after several days. When the client first awakes
what should the nurse say to the client - Correct Answer You are in the hospital. You were in an
accident and unconscious
On a hot, humid day. A client arrives at the emergency department presenting with confusion,
lethargy, and the following vitals temperature 104.1 degrees F, pulse, 132 beats/min, respirations 26
breaths/min, and blood pressure 106/66. what is the most appropriate intervention for this client? -
Correct Answer Start an intervenous line and infuse 0.9% saline solution
A nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse is
interpreted as a normal finding at the surgical site? - Correct Answer Serous drainage
A client with hypotension and an elevated temperature after working outside on a hot day is treated
in the emergency department. The nurse determines that discharge teaching has been effective
when the client makes which statement? - Correct Answer I should drink electrolyte sports drinks
when working outside in the hot weather
A triage officer is discussing mass casualty triage during a tabletop disaster drill. which statement
indicates further education is needed - Correct Answer Client is the urgent category would include
shock and airway obstruction
The nurse is caring for the client, who begins to experience seizure activity while in bed. Which of the
following actions by the nurse would be contraindicated? - Correct Answer Restraining the client's
limbs
A client is on intravenous heparin to treat a pulmonary embolism. The client reports bleeding gums
and PTT was 120 seconds - Correct Answer Stop the heparin and notify the healthcare provider
An emergency department charge nurse notes an increase in sick calls and bickering among the staff
after a week with multiple trauma incidents. which actions would the nurse take? - Correct Answer
Arrange for critical incident stress debriefing
