Rasmussen MDC 1 Exam 2 with
Complete Solutions
A 44 year old client with Diabetes asks how often a visit to the eye doctor is
recommended?
A. Annually
B. Every 6 months
C. No examination necessary until 50 years old
D. Every 2 years - ANSWER-A. Annually
A client has a synthetic cast placed for a right wrist fracture in the emergency
department. Which priority health teaching is important for the nurse to provide for this
client before returning home? Select all that apply.
A. "Keep your right arm below the level of your heart as often as possible."
B. "Use an ice pack for the first 24 hours to decrease tissue swelling."
C. "Move the fingers of the right hand frequently to promote blood flow."
D. "Report coolness or discoloration of your right hand to your doctor."
E. "Don't place any device under the cast to scratch the skin if it itches." - ANSWER-B,
C, D, E
A client is being discharged after surgery to correct a retinal detachment. Which
symptoms will the nurse teach the client to immediately report to the eye care provider?
Select all that apply.
A. Purulent discharge in the affected eye
B. Fever of 102° F (38.9° C)
C. Pupil that constricts in response to light
D. Improved visual acuity
E. Pain in the eye - ANSWER-A, B, E
A client recently diagnosed with primary bone cancer states, "My life is over. I'll never
get married now!" What is the nurse's best action at this time?
A. Refer the client to a clergy member or spiritual leader.
B. Ask the client what is meant by that statement.
C. Listen while the client expresses feelings.
D. Provide hope that marriage will happen. - ANSWER-C. Listen while the client
expresses feelings.
A client returns to the postanesthesia care unit (PACU) after an arthroscopy to repair a
knee injury. What is the nurse's priority when caring for this client?
A. Perform passive range-of-motion exercises.
B. Keep the affected leg immobilized.
C. Ensure that the patient uses the patient-controlled analgesia (PCA) pump.
D. Check the neurovascular status of the affected leg and foot. - ANSWER-D. Check
the neurovascular status of the affected leg and foot.
, A client who had an elective below-the-knee amputation (BKA) reports pain in the foot
that was amputated last week. What is the nurse's most appropriate response to the
client's pain?
A. "The pain will go away after the swelling decreases."
B. "That's phantom limb pain, and every amputee has that."
C. "Your foot has been amputated, so it's in your head."
D. "On a scale of 0 to 10, how would you rate your pain?" - ANSWER-D. "On a scale of
0 to 10, how would you rate your pain?"
A client who has a plaster leg splint reports a painful pressure sensation under the
elastic wrap that is holding the splint in place. What is the nurse's best initial action?
A. Remove the splint to reduce skin pressure.
B. Perform a neurovascular assessment.
C. Report the client's concern to the primary health care provider.
D. Inspect the skin under the elastic bandage. - ANSWER-B. Perform a neurovascular
assessment.
A lens opacity that distorts an image is called
A. Glaucoma
B. Cataract
C. Exopthalamus
D. Enopthalamus - ANSWER-B. Cataract
A nurse is performing a musculoskeletal assessment on an older adult living
independently. What normal physiologic changes of aging does the nurse expect?
Select all that apply.
A. Muscle atrophy
B. Slowed movement
C. Scoliosis
D. Arthritis
E. Widened gait - ANSWER-A, B,D, E
A nurse is planning care for a client who has a single lumen nasogastric tube for gastric
decompression. Which of the following actions should the nurse include in the plan of
care?
A. Set the suction machine at 120 mmHg.
B. Provide oral hygiene frequently.
C. Measure the amount of drainage from the NG tube.
D. Secure the NG tube to the client's gown.
E. Apply petroleum jelly to the clients nares. - ANSWER-B, C, D
A nurse is preparing to irrigate a client's wound. Which of the following actions should
the nurse take?
A. Use a 10mL syringe
B. Attach a 22 gauge catheter to the syringe
Complete Solutions
A 44 year old client with Diabetes asks how often a visit to the eye doctor is
recommended?
A. Annually
B. Every 6 months
C. No examination necessary until 50 years old
D. Every 2 years - ANSWER-A. Annually
A client has a synthetic cast placed for a right wrist fracture in the emergency
department. Which priority health teaching is important for the nurse to provide for this
client before returning home? Select all that apply.
A. "Keep your right arm below the level of your heart as often as possible."
B. "Use an ice pack for the first 24 hours to decrease tissue swelling."
C. "Move the fingers of the right hand frequently to promote blood flow."
D. "Report coolness or discoloration of your right hand to your doctor."
E. "Don't place any device under the cast to scratch the skin if it itches." - ANSWER-B,
C, D, E
A client is being discharged after surgery to correct a retinal detachment. Which
symptoms will the nurse teach the client to immediately report to the eye care provider?
Select all that apply.
A. Purulent discharge in the affected eye
B. Fever of 102° F (38.9° C)
C. Pupil that constricts in response to light
D. Improved visual acuity
E. Pain in the eye - ANSWER-A, B, E
A client recently diagnosed with primary bone cancer states, "My life is over. I'll never
get married now!" What is the nurse's best action at this time?
A. Refer the client to a clergy member or spiritual leader.
B. Ask the client what is meant by that statement.
C. Listen while the client expresses feelings.
D. Provide hope that marriage will happen. - ANSWER-C. Listen while the client
expresses feelings.
A client returns to the postanesthesia care unit (PACU) after an arthroscopy to repair a
knee injury. What is the nurse's priority when caring for this client?
A. Perform passive range-of-motion exercises.
B. Keep the affected leg immobilized.
C. Ensure that the patient uses the patient-controlled analgesia (PCA) pump.
D. Check the neurovascular status of the affected leg and foot. - ANSWER-D. Check
the neurovascular status of the affected leg and foot.
, A client who had an elective below-the-knee amputation (BKA) reports pain in the foot
that was amputated last week. What is the nurse's most appropriate response to the
client's pain?
A. "The pain will go away after the swelling decreases."
B. "That's phantom limb pain, and every amputee has that."
C. "Your foot has been amputated, so it's in your head."
D. "On a scale of 0 to 10, how would you rate your pain?" - ANSWER-D. "On a scale of
0 to 10, how would you rate your pain?"
A client who has a plaster leg splint reports a painful pressure sensation under the
elastic wrap that is holding the splint in place. What is the nurse's best initial action?
A. Remove the splint to reduce skin pressure.
B. Perform a neurovascular assessment.
C. Report the client's concern to the primary health care provider.
D. Inspect the skin under the elastic bandage. - ANSWER-B. Perform a neurovascular
assessment.
A lens opacity that distorts an image is called
A. Glaucoma
B. Cataract
C. Exopthalamus
D. Enopthalamus - ANSWER-B. Cataract
A nurse is performing a musculoskeletal assessment on an older adult living
independently. What normal physiologic changes of aging does the nurse expect?
Select all that apply.
A. Muscle atrophy
B. Slowed movement
C. Scoliosis
D. Arthritis
E. Widened gait - ANSWER-A, B,D, E
A nurse is planning care for a client who has a single lumen nasogastric tube for gastric
decompression. Which of the following actions should the nurse include in the plan of
care?
A. Set the suction machine at 120 mmHg.
B. Provide oral hygiene frequently.
C. Measure the amount of drainage from the NG tube.
D. Secure the NG tube to the client's gown.
E. Apply petroleum jelly to the clients nares. - ANSWER-B, C, D
A nurse is preparing to irrigate a client's wound. Which of the following actions should
the nurse take?
A. Use a 10mL syringe
B. Attach a 22 gauge catheter to the syringe
