1
NUR 2755 Exam 3 2025 Actual –
Multidimensional Care IV (MDC 4) |
Rasmussen | Verified Review with
Correct Answers
1. A client with acute respiratory distress syndrome (ARDS) is on mechanical
ventilation. Which intervention is priority to prevent ventilator-associated
pneumonia (VAP)?
A. Administer broad-spectrum antibiotics
B. Elevate the head of the bed to 30–45 degrees
C. Increase tidal volume to 10 mL/kg
D. Discontinue sedation daily
Correct Answer: B. Elevate the head of the bed to 30–45 degrees
Rationale: Elevating the head of the bed to 30–45 degrees reduces the risk of aspiration,
a primary cause of VAP. Antibiotics are used to treat, not prevent, VAP. Increasing tidal
volume may cause lung injury, and sedation management is secondary to positioning.
2. A client post-myocardial infarction (MI) reports chest pain unrelieved by
nitroglycerin. What is the nurse’s priority action?
A. Administer morphine sulfate
B. Notify the healthcare provider
C. Increase oxygen flow rate
D. Perform a 12-lead ECG
Correct Answer: B. Notify the healthcare provider
Rationale: Unrelieved chest pain post-MI suggests possible re-infarction or
complications, requiring immediate provider evaluation. Morphine, oxygen, and ECG are
important but secondary to notifying the provider for urgent intervention.
3. A client with septic shock has a mean arterial pressure (MAP) of 55 mmHg. Which
intervention is most appropriate?
A. Administer a fluid bolus of 0.9% sodium chloride
B. Initiate dopamine infusion
C. Place the client in Trendelenburg position
D. Reduce vasopressor dosage
Correct Answer: A. Administer a fluid bolus of 0.9% sodium chloride
Rationale: Septic shock with low MAP indicates hypoperfusion. A fluid bolus (30
mL/kg) is the first-line treatment to restore intravascular volume. Vasopressors like
dopamine are used if fluids fail, and Trendelenburg is not recommended.
4. A client with a traumatic brain injury (TBI) exhibits a Cushing’s triad. What are
the components of this triad?
A. Bradycardia, hypertension, irregular respirations
B. Tachycardia, hypotension, shallow respirations
C. Bradycardia, hypotension, regular respirations
, 2
D. Tachycardia, hypertension, deep respirations
Correct Answer: A. Bradycardia, hypertension, irregular respirations
Rationale: Cushing’s triad (bradycardia, hypertension, irregular respirations) indicates
increased intracranial pressure (ICP) in TBI, requiring immediate intervention to prevent
herniation.
5. A client with chronic obstructive pulmonary disease (COPD) exacerbation is
prescribed albuterol. What is the primary purpose of this medication?
A. Reduce airway inflammation
B. Relieve bronchospasm
C. Thin mucus secretions
D. Suppress cough reflex
Correct Answer: B. Relieve bronchospasm
Rationale: Albuterol, a beta-2 agonist, relaxes bronchial smooth muscles to relieve
bronchospasm in COPD. Steroids reduce inflammation, mucolytics thin secretions, and
antitussives suppress cough.
6. A client with heart failure is prescribed furosemide. Which laboratory value should
the nurse monitor closely?
A. Sodium
B. Potassium
C. Calcium
D. Magnesium
Correct Answer: B. Potassium
Rationale: Furosemide, a loop diuretic, increases potassium excretion, risking
hypokalemia, which can cause arrhythmias. Sodium, calcium, and magnesium are less
directly affected.
7. A client with a spinal cord injury at C5 is at risk for which complication?
A. Neurogenic bladder
B. Respiratory failure
C. Autonomic dysreflexia
D. Deep vein thrombosis
Correct Answer: B. Respiratory failure
Rationale: A C5 spinal cord injury affects the diaphragm (innervated by C3–C5),
increasing the risk of respiratory failure due to impaired ventilation. Other complications
are possible but less immediate.
8. A client with burns covering 40% of their body surface area is admitted. What is the
priority nursing intervention?
A. Administer pain medication
B. Initiate fluid resuscitation
C. Apply topical antibiotics
D. Perform wound debridement
Correct Answer: B. Initiate fluid resuscitation
Rationale: Fluid resuscitation (e.g., Parkland formula) is critical in major burns to
prevent hypovolemic shock due to fluid loss. Pain management, antibiotics, and
debridement are secondary.
9. A client with a pulmonary embolism (PE) is prescribed heparin. What is the
therapeutic goal of this medication?
, 3
A. Dissolve the existing clot
B. Prevent further clot formation
C. Reduce pulmonary edema
D. Improve oxygenation
Correct Answer: B. Prevent further clot formation
Rationale: Heparin, an anticoagulant, prevents new clots from forming and existing clots
from growing, reducing PE risk. Fibrinolytics dissolve clots, and other options are
unrelated.
10. A client with diabetic ketoacidosis (DKA) has a blood glucose of 600 mg/dL. What is
the priority nursing intervention?
A. Administer regular insulin IV
B. Provide oral glucose solution
C. Initiate potassium replacement
D. Administer sodium bicarbonate
Correct Answer: A. Administer regular insulin IV
Rationale: Insulin corrects hyperglycemia and halts ketone production in DKA. Fluid
resuscitation is also critical, but insulin is the primary treatment for the underlying cause.
11. A client with a tracheostomy is experiencing increased secretions. What is the
nurse’s priority action?
A. Suction the tracheostomy
B. Change the tracheostomy tube
C. Administer oxygen via mask
D. Notify the respiratory therapist
Correct Answer: A. Suction the tracheostomy
Rationale: Suctioning clears secretions to maintain airway patency. Tube changes,
oxygen masks, and notifications are secondary unless suctioning fails.
12. A client with acute kidney injury (AKI) has a potassium level of 6.5 mEq/L. What is
the priority intervention?
A. Administer kayexalate
B. Initiate dialysis
C. Administer calcium gluconate
D. Restrict potassium intake
Correct Answer: C. Administer calcium gluconate
Rationale: Hyperkalemia (≥6.5 mEq/L) risks cardiac arrhythmias. Calcium gluconate
stabilizes cardiac membranes immediately, while kayexalate, dialysis, and diet
restrictions are slower-acting.
13. A client with a chest tube for pneumothorax reports sudden shortness of breath.
The nurse notes no drainage in the collection chamber. What is the likely cause?
A. Tube dislodgement
B. Tube occlusion
C. Lung re-expansion
D. Pleural effusion
Correct Answer: B. Tube occlusion
Rationale: Sudden dyspnea and no drainage suggest chest tube occlusion, preventing air
evacuation. Dislodgement would show air leaks, and re-expansion or effusion have
different presentations.
NUR 2755 Exam 3 2025 Actual –
Multidimensional Care IV (MDC 4) |
Rasmussen | Verified Review with
Correct Answers
1. A client with acute respiratory distress syndrome (ARDS) is on mechanical
ventilation. Which intervention is priority to prevent ventilator-associated
pneumonia (VAP)?
A. Administer broad-spectrum antibiotics
B. Elevate the head of the bed to 30–45 degrees
C. Increase tidal volume to 10 mL/kg
D. Discontinue sedation daily
Correct Answer: B. Elevate the head of the bed to 30–45 degrees
Rationale: Elevating the head of the bed to 30–45 degrees reduces the risk of aspiration,
a primary cause of VAP. Antibiotics are used to treat, not prevent, VAP. Increasing tidal
volume may cause lung injury, and sedation management is secondary to positioning.
2. A client post-myocardial infarction (MI) reports chest pain unrelieved by
nitroglycerin. What is the nurse’s priority action?
A. Administer morphine sulfate
B. Notify the healthcare provider
C. Increase oxygen flow rate
D. Perform a 12-lead ECG
Correct Answer: B. Notify the healthcare provider
Rationale: Unrelieved chest pain post-MI suggests possible re-infarction or
complications, requiring immediate provider evaluation. Morphine, oxygen, and ECG are
important but secondary to notifying the provider for urgent intervention.
3. A client with septic shock has a mean arterial pressure (MAP) of 55 mmHg. Which
intervention is most appropriate?
A. Administer a fluid bolus of 0.9% sodium chloride
B. Initiate dopamine infusion
C. Place the client in Trendelenburg position
D. Reduce vasopressor dosage
Correct Answer: A. Administer a fluid bolus of 0.9% sodium chloride
Rationale: Septic shock with low MAP indicates hypoperfusion. A fluid bolus (30
mL/kg) is the first-line treatment to restore intravascular volume. Vasopressors like
dopamine are used if fluids fail, and Trendelenburg is not recommended.
4. A client with a traumatic brain injury (TBI) exhibits a Cushing’s triad. What are
the components of this triad?
A. Bradycardia, hypertension, irregular respirations
B. Tachycardia, hypotension, shallow respirations
C. Bradycardia, hypotension, regular respirations
, 2
D. Tachycardia, hypertension, deep respirations
Correct Answer: A. Bradycardia, hypertension, irregular respirations
Rationale: Cushing’s triad (bradycardia, hypertension, irregular respirations) indicates
increased intracranial pressure (ICP) in TBI, requiring immediate intervention to prevent
herniation.
5. A client with chronic obstructive pulmonary disease (COPD) exacerbation is
prescribed albuterol. What is the primary purpose of this medication?
A. Reduce airway inflammation
B. Relieve bronchospasm
C. Thin mucus secretions
D. Suppress cough reflex
Correct Answer: B. Relieve bronchospasm
Rationale: Albuterol, a beta-2 agonist, relaxes bronchial smooth muscles to relieve
bronchospasm in COPD. Steroids reduce inflammation, mucolytics thin secretions, and
antitussives suppress cough.
6. A client with heart failure is prescribed furosemide. Which laboratory value should
the nurse monitor closely?
A. Sodium
B. Potassium
C. Calcium
D. Magnesium
Correct Answer: B. Potassium
Rationale: Furosemide, a loop diuretic, increases potassium excretion, risking
hypokalemia, which can cause arrhythmias. Sodium, calcium, and magnesium are less
directly affected.
7. A client with a spinal cord injury at C5 is at risk for which complication?
A. Neurogenic bladder
B. Respiratory failure
C. Autonomic dysreflexia
D. Deep vein thrombosis
Correct Answer: B. Respiratory failure
Rationale: A C5 spinal cord injury affects the diaphragm (innervated by C3–C5),
increasing the risk of respiratory failure due to impaired ventilation. Other complications
are possible but less immediate.
8. A client with burns covering 40% of their body surface area is admitted. What is the
priority nursing intervention?
A. Administer pain medication
B. Initiate fluid resuscitation
C. Apply topical antibiotics
D. Perform wound debridement
Correct Answer: B. Initiate fluid resuscitation
Rationale: Fluid resuscitation (e.g., Parkland formula) is critical in major burns to
prevent hypovolemic shock due to fluid loss. Pain management, antibiotics, and
debridement are secondary.
9. A client with a pulmonary embolism (PE) is prescribed heparin. What is the
therapeutic goal of this medication?
, 3
A. Dissolve the existing clot
B. Prevent further clot formation
C. Reduce pulmonary edema
D. Improve oxygenation
Correct Answer: B. Prevent further clot formation
Rationale: Heparin, an anticoagulant, prevents new clots from forming and existing clots
from growing, reducing PE risk. Fibrinolytics dissolve clots, and other options are
unrelated.
10. A client with diabetic ketoacidosis (DKA) has a blood glucose of 600 mg/dL. What is
the priority nursing intervention?
A. Administer regular insulin IV
B. Provide oral glucose solution
C. Initiate potassium replacement
D. Administer sodium bicarbonate
Correct Answer: A. Administer regular insulin IV
Rationale: Insulin corrects hyperglycemia and halts ketone production in DKA. Fluid
resuscitation is also critical, but insulin is the primary treatment for the underlying cause.
11. A client with a tracheostomy is experiencing increased secretions. What is the
nurse’s priority action?
A. Suction the tracheostomy
B. Change the tracheostomy tube
C. Administer oxygen via mask
D. Notify the respiratory therapist
Correct Answer: A. Suction the tracheostomy
Rationale: Suctioning clears secretions to maintain airway patency. Tube changes,
oxygen masks, and notifications are secondary unless suctioning fails.
12. A client with acute kidney injury (AKI) has a potassium level of 6.5 mEq/L. What is
the priority intervention?
A. Administer kayexalate
B. Initiate dialysis
C. Administer calcium gluconate
D. Restrict potassium intake
Correct Answer: C. Administer calcium gluconate
Rationale: Hyperkalemia (≥6.5 mEq/L) risks cardiac arrhythmias. Calcium gluconate
stabilizes cardiac membranes immediately, while kayexalate, dialysis, and diet
restrictions are slower-acting.
13. A client with a chest tube for pneumothorax reports sudden shortness of breath.
The nurse notes no drainage in the collection chamber. What is the likely cause?
A. Tube dislodgement
B. Tube occlusion
C. Lung re-expansion
D. Pleural effusion
Correct Answer: B. Tube occlusion
Rationale: Sudden dyspnea and no drainage suggest chest tube occlusion, preventing air
evacuation. Dislodgement would show air leaks, and re-expansion or effusion have
different presentations.
