Multidimensional Care IV
MDC FINAL EXAM
Rasmussen College
passing score of 90% or higher
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,1. A nurse is reviewing the preoperative checklist for a client scheduled for an
elective cholecystectomy. Which finding should be reported to the provider
immediately?
A. The client has not voided since morning
B. The client ate toast with jelly 5 hours ago
C. The consent form is signed and witnessed
D. The client states they are allergic to latex:
B. The client ate toast with jelly 5 hours ago
Expert Rationale: Clients must be NPO for at least 6-8 hours before general
anesthesia to reduce the risk of aspiration during
surgery. Eating within 5 hours is unsafe and must be reported immediately.
2. The nurse is caring for a client with a Jackson-Pratt (JP) drain after abdominal
surgery. Which finding should be reported to the provider?
A. Serosanguinous drainage in the bulb
B. Drainage of 120 mL in 2 hours
C. The bulb is compressed and secured
D. No output noted in 4 hours:
B. Drainage of 120 mL in 2 hours
Expert Rationale: Drainage greater than 50-100 mL/hour may indicate internal
bleeding or a surgical complication and should
be reported to the provider immediately.
,3. A nurse is assessing a client with a suspected tension pneumothorax. Which
finding requires immediate intervention?
A. Diminished breath sounds on one side
B. Sudden chest pain
C. Tracheal deviation away from the affected side
D. Respiratory rate of 24 breaths per minute:
C. Tracheal deviation away from the affected side
Expert Rationale: Tracheal deviation is a late and life-threatening sign of tension
pneumothorax. It requires immediate needle
decompression to relieve pressure and prevent cardiovascular collapse.
4. A client is suspected of having a pulmonary embolism. What is the nurse's
priority action?
A. Prepare the client for a chest x-ray
B. Administer morphine sulfate
C. Apply oxygen via non-rebreather mask
D. Encourage the client to ambulate:
C. Apply oxygen via non-rebreather mask
Expert Rationale: Improving oxygenation is the first priority to treat hypoxia
caused by the embolism. Further diagnostics and
medications come afterward.
, 5. A nurse is caring for a client with burns covering 35% of the total body surface
area. Which assessment finding indicates effective fluid resuscitation?
A. Urine output of 20 mL/hr
B. Heart rate of 130 bpm
C. Capillary refill of 5 seconds
D. Blood pressure of 110/70 mmHg:
D. Blood pressure of 110/70 mmHg
Expert Rationale: A stable blood pressure indicates effective perfusion and
adequate fluid replacement. Low urine output and tachycardia would suggest
hypovolemia.
6. The nurse is assessing a client's surgical incision 24 hours after an abdominal
procedure. Which finding should the nurse report to the provider immediately?
A. Slight swelling and pink edges around the incision
B. Serosanguinous drainage noted on dressing
C. Separation of the incision with bowel visible
D. Pain rated 5 out of 10 at the incision site:
C. Separation of the incision with bowel visible
Expert Rationale: Evisceration is a surgical emergency that requires the incision to
be covered with sterile saline-soaked gauze and immediate provider notification.