NUR 2356 / NUR2356 Multidimensional Care I Final Exam /
MDC 1 FINAL EXAM REVIEW | ACTUAL EXAM | Highly Rated
Quiz Bank | Questions and Answers | Latest 2025/2026 |
Rasmussen College
1
The nurse is caring for a client with a stage III pressure injury on the sacrum. Which
intervention should the nurse implement first?
A. Apply a hydrocolloid dressing
B. Obtain a wound culture
C. Turn the client every 2 hours
D. Administer IV antibiotics
Correct Answer: C
Rationale: The first priority is to eliminate the cause of pressure by repositioning
(turning) the client every 2 hours to prevent further tissue ischemia. Dressings and
cultures are important but do not address the etiology. IV antibiotics are prescribed only
if infection is confirmed.
2
A client with COPD is receiving oxygen at 5 L/min via nasal cannula. The client becomes
increasingly somnolent and his PaCO₂ rises from 55 to 72 mmHg. Which action should
the nurse take first?
,A. Increase oxygen to 6 L/min
B. Obtain a stat ABG
C. Notify the provider immediately
D. Place the client in high-Fowler position
Correct Answer: C
Rationale: The client is exhibiting signs of acute CO₂ narcosis caused by high oxygen
flow blunting the hypoxic respiratory drive in COPD. The provider must be notified
immediately to adjust oxygen delivery (e.g., titrate to SpO₂ 88–92%). While ABG and
positioning are helpful, delaying provider notification risks respiratory arrest.
3
Which laboratory value is most important for the nurse to monitor before administering
enoxaparin?
A. PT/INR
B. aPTT
C. Platelet count
D. Hemoglobin
Correct Answer: C
Rationale: Enoxaparin is a low-molecular-weight heparin that can cause heparin-induced
thrombocytopenia (HIT); therefore, a baseline and periodic platelet count is essential.
PT/INR and aPTT are not used to monitor LMWH.
,4
The nurse is delegating tasks to an assistive personnel (AP). Which task should the
nurse retain?
A. Measuring vital signs on a stable post-op client
B. Recording intake and output
C. Performing blood glucose monitoring
D. Ambulating a client with a new PCA pump
Correct Answer: C
Rationale: Blood glucose monitoring requires clinical judgment and cannot be delegated
to AP. Vital signs, I&O, and ambulation of stable clients are within AP scope under nurse
supervision.
5
A client with heart failure is prescribed furosemide 40 mg IV BID. Which finding
indicates the medication is effective?
A. Weight loss of 1 kg in 24 hours
B. Urine output 30 mL/hr
C. Serum potassium 3.0 mEq/L
D. BUN 35 mg/dL
Correct Answer: A
, Rationale: A 1 kg weight loss equals approximately 1 liter of fluid loss, indicating
effective diuresis. UOP 30 mL/hr is below normal (≥30 mL/hr minimum, but goal >50).
Hypokalemia and rising BUN are side effects, not therapeutic effects.
6
The nurse is caring for a client with a chest tube after a thoracotomy. The chest tube
becomes disconnected from the drainage system. What is the nurse’s immediate
action?
A. Reconnect the tube quickly
B. Clamp the chest tube with a hemostat
C. Place the distal end in sterile saline
D. Notify the provider immediately
Correct Answer: C
Rationale: Submerging the distal end in sterile saline creates a temporary water seal,
preventing atmospheric air from entering the pleural space. Clamping can create a
tension pneumothorax if an air leak exists.
7
A postoperative client suddenly reports severe calf pain. The nurse notes unilateral
edema and warmth. Which action is priority?
A. Elevate the leg on two pillows
B. Apply a heating pad
C. Measure calf circumference
MDC 1 FINAL EXAM REVIEW | ACTUAL EXAM | Highly Rated
Quiz Bank | Questions and Answers | Latest 2025/2026 |
Rasmussen College
1
The nurse is caring for a client with a stage III pressure injury on the sacrum. Which
intervention should the nurse implement first?
A. Apply a hydrocolloid dressing
B. Obtain a wound culture
C. Turn the client every 2 hours
D. Administer IV antibiotics
Correct Answer: C
Rationale: The first priority is to eliminate the cause of pressure by repositioning
(turning) the client every 2 hours to prevent further tissue ischemia. Dressings and
cultures are important but do not address the etiology. IV antibiotics are prescribed only
if infection is confirmed.
2
A client with COPD is receiving oxygen at 5 L/min via nasal cannula. The client becomes
increasingly somnolent and his PaCO₂ rises from 55 to 72 mmHg. Which action should
the nurse take first?
,A. Increase oxygen to 6 L/min
B. Obtain a stat ABG
C. Notify the provider immediately
D. Place the client in high-Fowler position
Correct Answer: C
Rationale: The client is exhibiting signs of acute CO₂ narcosis caused by high oxygen
flow blunting the hypoxic respiratory drive in COPD. The provider must be notified
immediately to adjust oxygen delivery (e.g., titrate to SpO₂ 88–92%). While ABG and
positioning are helpful, delaying provider notification risks respiratory arrest.
3
Which laboratory value is most important for the nurse to monitor before administering
enoxaparin?
A. PT/INR
B. aPTT
C. Platelet count
D. Hemoglobin
Correct Answer: C
Rationale: Enoxaparin is a low-molecular-weight heparin that can cause heparin-induced
thrombocytopenia (HIT); therefore, a baseline and periodic platelet count is essential.
PT/INR and aPTT are not used to monitor LMWH.
,4
The nurse is delegating tasks to an assistive personnel (AP). Which task should the
nurse retain?
A. Measuring vital signs on a stable post-op client
B. Recording intake and output
C. Performing blood glucose monitoring
D. Ambulating a client with a new PCA pump
Correct Answer: C
Rationale: Blood glucose monitoring requires clinical judgment and cannot be delegated
to AP. Vital signs, I&O, and ambulation of stable clients are within AP scope under nurse
supervision.
5
A client with heart failure is prescribed furosemide 40 mg IV BID. Which finding
indicates the medication is effective?
A. Weight loss of 1 kg in 24 hours
B. Urine output 30 mL/hr
C. Serum potassium 3.0 mEq/L
D. BUN 35 mg/dL
Correct Answer: A
, Rationale: A 1 kg weight loss equals approximately 1 liter of fluid loss, indicating
effective diuresis. UOP 30 mL/hr is below normal (≥30 mL/hr minimum, but goal >50).
Hypokalemia and rising BUN are side effects, not therapeutic effects.
6
The nurse is caring for a client with a chest tube after a thoracotomy. The chest tube
becomes disconnected from the drainage system. What is the nurse’s immediate
action?
A. Reconnect the tube quickly
B. Clamp the chest tube with a hemostat
C. Place the distal end in sterile saline
D. Notify the provider immediately
Correct Answer: C
Rationale: Submerging the distal end in sterile saline creates a temporary water seal,
preventing atmospheric air from entering the pleural space. Clamping can create a
tension pneumothorax if an air leak exists.
7
A postoperative client suddenly reports severe calf pain. The nurse notes unilateral
edema and warmth. Which action is priority?
A. Elevate the leg on two pillows
B. Apply a heating pad
C. Measure calf circumference
