Rasmussen College MDC 4 Exam
Rasmussen College MDC 4 Exam 2
Verified Questions and Answers with Detailed
Rationales 2025 A+
1. Which of the following nursing diagnoses would be appropriate for a client with heart
failure? Select all that apply.
1. Ineffective tissue perfusion related to decreased peripheral blood flow secondary to
decreased cardiac output.
2. Activity intolerance related to increased cardiac output.
3. Decreased cardiac output related to structural and functional changes.
4. Impaired gas exchange related to decreased sympathetic nervous system activity. - Answer
✓✓10. Answer: 1 and 3.
HF is a result of structural and functional abnormalities of the heart tissue muscle. The heart
muscle becomes weak and does not adequately pump the blood out of the chambers. As a
result, blood pools in the left ventricle and backs up into the left atrium, and eventually into
the lungs. Therefore, greater amounts of blood remain in the ventricle after contraction
thereby decreasing cardiac output. In addition, this pooling leads to thrombus formation and
ineffective tissue perfusion because of the decrease in blood flow to the other organs and
tissues of the body. Typically, these clients have an ejection fraction of less than 50% and
poorly tolerate activity. Activity intolerance is related to a decrease, not increase, in cardiac
output. Gas exchange is impaired. However, the decrease in cardiac output triggers
compensatory mechanisms, such as an increase in sympathetic nervous system activity.
2. When caring for a client with a central venous line, which of the following nursing actions
should be implemented in the plan of care for chemotherapy administration? Select all that
apply.
1. Verify patency of the line by the presence of a blood return at regular intervals.
, Rasmussen College MDC 4 Exam
2. Inspect the insertion site for swelling, erythema, or drainage.
3. Administer a cytotoxic agent to keep the regimen on schedule even if blood return is not
present.
A+ 5
, Rasmussen College MDC 4 Exam
4. If unable to aspirate blood, reposition the client and encourage the client to cough.
5. Contact the health care provider about verifying placement if the status is questionable. -
Answer ✓✓11. Answer: 1, 2, 4, 5.
A major concern with intravenous administration of cytotoxic agents is vessel irritation or
extravasation. The Oncology Nursing Society and hospital guidelines require frequent
evaluation of blood return when administering vesicant or non vesicant chemotherapy due to
the risk of extravasation. These guidelines apply to peripheral and central venous lines. In
addition, central venous lines may be long-term venous access devices. Thus, difficulty
drawing or aspirating blood may indicate the line is against the vessel wall or may indicate the
line has occlusion. Having the client cough or move position may change the status of the line
if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-
ray study to verify placement if the status is questionable and may require a declotting
regimen.
3. A 20-year old college student has been brought to the psychiatric hospital by her parents.
Her admitting diagnosis is borderline personality disorder. When talking with the parents,
which information would the nurse expect to be included in the client's history? Select all that
apply.
1. Impulsiveness2. Lability of mood3. Ritualistic behavior4. psychomotor retardation5. Self-
destructive behavior - Answer ✓✓12. Answer: 1, 2, 5.
4. When assessing a client diagnosed with impulse control disorder, the nurse observes
violent, aggressive, and assaultive behavior. Which of the following assessment data is the
nurse also likely to find? Select all that apply.
1. The client functions well in other areas of his life.
2. The degree of aggressiveness is out of proportion to the stressor.
3. The violent behavior is most often justified by the stressor.
4. The client has a history of parental alcoholism and chaotic, abusive family life.5. The client
has no remorse about the inability to control his anger. - Answer ✓✓13. Answer: 1, 2, 4.
A+ 6
, Rasmussen College MDC 4 Exam
A client with an impulse control disorder who displays violent, aggressive, and assaultive
behavior generally functions well in other areas of his life. The degree of aggressiveness is
typically out of proportion with the stressor. Such a client commonly has a history of parental
alcoholism and a chaotic family life, and often verbalizes sincere remorse and guilt for the
aggressive behavior.
5. Which of the following nursing interventions are written correctly? (Select all that apply.)
1. Apply continuous passive motion machine during day.
2. Perform neurovascular checks.
3. Elevate head of bed 30 degrees before meals.
4. Change dressing once a shift. - Answer ✓✓14. Answer: 3.
It is specific in what to do and when.
6. The nurse is monitoring a client receiving peritoneal dialysis and nurse notes that a client's
outflow is less than the inflow. Select actions that the nurse should take.
1. Place the client in good body alignment2. Check the level of the drainage bag3. Contact the
physician - Answer ✓✓15. Answer: 1, 2, 4, 5.
If outflow drainage is inadequate, the nurse attempts to stimulate outflow by changing the
client's position. Turning the client to the other side or making sure that the client is in good
body alignment may assist with outflow drainage. The drainage bag needs to be lower than
the client's abdomen to enhance gravity drainage. The connecting tubing and the peritoneal
dialysis system is also checked for kinks or twisting and the clamps on the system are checked
to ensure that they are open. There is no reason to contact the physician.
7. The nurse is caring for a hospitalized client who has chronic renal failure. Which of the
following nursing diagnoses are most appropriate for this client? Select all that apply.
1. Excess Fluid Volume2. Imbalanced Nutrition; Less than Body Requirements3. Activity
Intolerance4. Impaired Gas Exchange5. Pain. - Answer ✓✓16. Answer: 1, 2, 3.
A+ 7
Rasmussen College MDC 4 Exam 2
Verified Questions and Answers with Detailed
Rationales 2025 A+
1. Which of the following nursing diagnoses would be appropriate for a client with heart
failure? Select all that apply.
1. Ineffective tissue perfusion related to decreased peripheral blood flow secondary to
decreased cardiac output.
2. Activity intolerance related to increased cardiac output.
3. Decreased cardiac output related to structural and functional changes.
4. Impaired gas exchange related to decreased sympathetic nervous system activity. - Answer
✓✓10. Answer: 1 and 3.
HF is a result of structural and functional abnormalities of the heart tissue muscle. The heart
muscle becomes weak and does not adequately pump the blood out of the chambers. As a
result, blood pools in the left ventricle and backs up into the left atrium, and eventually into
the lungs. Therefore, greater amounts of blood remain in the ventricle after contraction
thereby decreasing cardiac output. In addition, this pooling leads to thrombus formation and
ineffective tissue perfusion because of the decrease in blood flow to the other organs and
tissues of the body. Typically, these clients have an ejection fraction of less than 50% and
poorly tolerate activity. Activity intolerance is related to a decrease, not increase, in cardiac
output. Gas exchange is impaired. However, the decrease in cardiac output triggers
compensatory mechanisms, such as an increase in sympathetic nervous system activity.
2. When caring for a client with a central venous line, which of the following nursing actions
should be implemented in the plan of care for chemotherapy administration? Select all that
apply.
1. Verify patency of the line by the presence of a blood return at regular intervals.
, Rasmussen College MDC 4 Exam
2. Inspect the insertion site for swelling, erythema, or drainage.
3. Administer a cytotoxic agent to keep the regimen on schedule even if blood return is not
present.
A+ 5
, Rasmussen College MDC 4 Exam
4. If unable to aspirate blood, reposition the client and encourage the client to cough.
5. Contact the health care provider about verifying placement if the status is questionable. -
Answer ✓✓11. Answer: 1, 2, 4, 5.
A major concern with intravenous administration of cytotoxic agents is vessel irritation or
extravasation. The Oncology Nursing Society and hospital guidelines require frequent
evaluation of blood return when administering vesicant or non vesicant chemotherapy due to
the risk of extravasation. These guidelines apply to peripheral and central venous lines. In
addition, central venous lines may be long-term venous access devices. Thus, difficulty
drawing or aspirating blood may indicate the line is against the vessel wall or may indicate the
line has occlusion. Having the client cough or move position may change the status of the line
if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-
ray study to verify placement if the status is questionable and may require a declotting
regimen.
3. A 20-year old college student has been brought to the psychiatric hospital by her parents.
Her admitting diagnosis is borderline personality disorder. When talking with the parents,
which information would the nurse expect to be included in the client's history? Select all that
apply.
1. Impulsiveness2. Lability of mood3. Ritualistic behavior4. psychomotor retardation5. Self-
destructive behavior - Answer ✓✓12. Answer: 1, 2, 5.
4. When assessing a client diagnosed with impulse control disorder, the nurse observes
violent, aggressive, and assaultive behavior. Which of the following assessment data is the
nurse also likely to find? Select all that apply.
1. The client functions well in other areas of his life.
2. The degree of aggressiveness is out of proportion to the stressor.
3. The violent behavior is most often justified by the stressor.
4. The client has a history of parental alcoholism and chaotic, abusive family life.5. The client
has no remorse about the inability to control his anger. - Answer ✓✓13. Answer: 1, 2, 4.
A+ 6
, Rasmussen College MDC 4 Exam
A client with an impulse control disorder who displays violent, aggressive, and assaultive
behavior generally functions well in other areas of his life. The degree of aggressiveness is
typically out of proportion with the stressor. Such a client commonly has a history of parental
alcoholism and a chaotic family life, and often verbalizes sincere remorse and guilt for the
aggressive behavior.
5. Which of the following nursing interventions are written correctly? (Select all that apply.)
1. Apply continuous passive motion machine during day.
2. Perform neurovascular checks.
3. Elevate head of bed 30 degrees before meals.
4. Change dressing once a shift. - Answer ✓✓14. Answer: 3.
It is specific in what to do and when.
6. The nurse is monitoring a client receiving peritoneal dialysis and nurse notes that a client's
outflow is less than the inflow. Select actions that the nurse should take.
1. Place the client in good body alignment2. Check the level of the drainage bag3. Contact the
physician - Answer ✓✓15. Answer: 1, 2, 4, 5.
If outflow drainage is inadequate, the nurse attempts to stimulate outflow by changing the
client's position. Turning the client to the other side or making sure that the client is in good
body alignment may assist with outflow drainage. The drainage bag needs to be lower than
the client's abdomen to enhance gravity drainage. The connecting tubing and the peritoneal
dialysis system is also checked for kinks or twisting and the clamps on the system are checked
to ensure that they are open. There is no reason to contact the physician.
7. The nurse is caring for a hospitalized client who has chronic renal failure. Which of the
following nursing diagnoses are most appropriate for this client? Select all that apply.
1. Excess Fluid Volume2. Imbalanced Nutrition; Less than Body Requirements3. Activity
Intolerance4. Impaired Gas Exchange5. Pain. - Answer ✓✓16. Answer: 1, 2, 3.
A+ 7
