NUR2392 MULTIDIMENSIONAL CARE 2 FINAL EXAM/MDC2
FINAL ACTUAL EXAM 75 QUESTIONS AND CORRECT
DETAILED ANSWERS|AGRADE (RASMUSSEN COLLEGE)
A nurse assesses a client with diabetes mellitus who is admitted with an acid-base imbalance. The client's
arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3- 18 mEq/L. Which
manifestation should the nurse identify as an example of the client's compensation mechanism? - answer>>
Increased rate and depth of respirations
A nurse assesses a client who is experiencing an acid-base imbalance. The client's arterial blood gas values
are pH 7.34, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3- 19 mEq/L. Which assessment should the nurse
perform first? - answer>> Cardiac rate and rhythm
A nurse is caring for a client who is experiencing moderate metabolic alkalosis. Which action should the nurse
take? - answer>> Teach the client fall prevention measures
A nurse is planning care for a client who is hyperventilating. The client's arterial blood gas values are pH 7.30,
PaO2 94 mm Hg, PaCO2 31 mm Hg, and HCO3- 26 mEq/L. Which question should the nurse ask when
developing this client's plan of care? - answer>> "You appear anxious. What is causing your distress?"
A nurse is caring for a client who has chronic emphysema and is receiving oxygen therapy at 6 L/min via nasal
cannula. The following clinical data are available:
Arterial Blood Gases
Vital Signs
pH = 7.28 Pulse rate = 96 beats/min
PaO2 = 85 mm Hg Blood pressure = 135/45
PaCO2 = 55 mm Hg Respiratory rate = 6 breaths/min
HCO3- = 26 mEq/L O2 saturation = 88%
Which action should the nurse take first? - answer>> Notify the Rapid Response Team and provide ventilation
support
A nurse is caring for a client who has just had a central venous access line inserted. Which action should the
nurse take next? - answer>> Ensure an x-ray is completed to confirm placement.
A nurse assesses a client who has a radial artery catheter. Which assessment should the nurse complete first?
- answer>> Presence of an ulnar pulse
, A nurse is caring for a client who is having a subclavian central venous catheter inserted. The client begins to
report chest pain and difficulty breathing. After administering oxygen, which action should the nurse take next?
answer>> Prepare to assist with chest tube insertion.
A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment
finding requires immediate intervention from the nurse? - answer>> Report of headache and stiff neck.
A nurse is caring for a client with a peripheral vascular access device who is experiencing pain, redness, and
swelling at the site. After removing the device, which action should the nurse take to relieve pain? - answer>>
Place warm compresses to the site
A home care nurse prepares to administer intravenous medication to a client. The nurse assesses the site and
reviews the client's chart prior to administering the medication:
Client: Thomas Jackson
DOB: 5/3/1936
Gender: Male
January 23 (Today): Right upper extremity PICC is intact, patent, and has a good blood return. Site clean and
free from manifestations of infiltration, irritation, and infection. -Sue Franks, RN
January 20: Purulent drainage from sacral wound. Wound cleansed and dressing changed. Dr. Smith notified
and updated on client status. New orders received for intravenous antibiotics. -Sue Franks, RN
January 13: Client alert and oriented. Sacral wound dressing changed. -Sue Franks, RN
January 6: Right upper extremity PICC inserted. No complications. Discharged with home health care. -Dr.
Smith
Based on the information provided, which action should the nurse take? - answer>> Administer the prescribed
medication
A hospitalized older adult has been assessed at high risk for skin breakdown. Which actions does the registere
nurse (RN) delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) - answer>> -Keep the
client's skin dry
-Obtain a pressure-relieving mattress
-Turn the client every 2 hours
A nurse on the postoperative unit administers many opioid analgesics. What actions by the nurse are best to
prevent unwanted sedation as a complication of these medications? (Select all that apply.) - answer>> -Avoid
using other medications that cause sedation.
FINAL ACTUAL EXAM 75 QUESTIONS AND CORRECT
DETAILED ANSWERS|AGRADE (RASMUSSEN COLLEGE)
A nurse assesses a client with diabetes mellitus who is admitted with an acid-base imbalance. The client's
arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3- 18 mEq/L. Which
manifestation should the nurse identify as an example of the client's compensation mechanism? - answer>>
Increased rate and depth of respirations
A nurse assesses a client who is experiencing an acid-base imbalance. The client's arterial blood gas values
are pH 7.34, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3- 19 mEq/L. Which assessment should the nurse
perform first? - answer>> Cardiac rate and rhythm
A nurse is caring for a client who is experiencing moderate metabolic alkalosis. Which action should the nurse
take? - answer>> Teach the client fall prevention measures
A nurse is planning care for a client who is hyperventilating. The client's arterial blood gas values are pH 7.30,
PaO2 94 mm Hg, PaCO2 31 mm Hg, and HCO3- 26 mEq/L. Which question should the nurse ask when
developing this client's plan of care? - answer>> "You appear anxious. What is causing your distress?"
A nurse is caring for a client who has chronic emphysema and is receiving oxygen therapy at 6 L/min via nasal
cannula. The following clinical data are available:
Arterial Blood Gases
Vital Signs
pH = 7.28 Pulse rate = 96 beats/min
PaO2 = 85 mm Hg Blood pressure = 135/45
PaCO2 = 55 mm Hg Respiratory rate = 6 breaths/min
HCO3- = 26 mEq/L O2 saturation = 88%
Which action should the nurse take first? - answer>> Notify the Rapid Response Team and provide ventilation
support
A nurse is caring for a client who has just had a central venous access line inserted. Which action should the
nurse take next? - answer>> Ensure an x-ray is completed to confirm placement.
A nurse assesses a client who has a radial artery catheter. Which assessment should the nurse complete first?
- answer>> Presence of an ulnar pulse
, A nurse is caring for a client who is having a subclavian central venous catheter inserted. The client begins to
report chest pain and difficulty breathing. After administering oxygen, which action should the nurse take next?
answer>> Prepare to assist with chest tube insertion.
A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment
finding requires immediate intervention from the nurse? - answer>> Report of headache and stiff neck.
A nurse is caring for a client with a peripheral vascular access device who is experiencing pain, redness, and
swelling at the site. After removing the device, which action should the nurse take to relieve pain? - answer>>
Place warm compresses to the site
A home care nurse prepares to administer intravenous medication to a client. The nurse assesses the site and
reviews the client's chart prior to administering the medication:
Client: Thomas Jackson
DOB: 5/3/1936
Gender: Male
January 23 (Today): Right upper extremity PICC is intact, patent, and has a good blood return. Site clean and
free from manifestations of infiltration, irritation, and infection. -Sue Franks, RN
January 20: Purulent drainage from sacral wound. Wound cleansed and dressing changed. Dr. Smith notified
and updated on client status. New orders received for intravenous antibiotics. -Sue Franks, RN
January 13: Client alert and oriented. Sacral wound dressing changed. -Sue Franks, RN
January 6: Right upper extremity PICC inserted. No complications. Discharged with home health care. -Dr.
Smith
Based on the information provided, which action should the nurse take? - answer>> Administer the prescribed
medication
A hospitalized older adult has been assessed at high risk for skin breakdown. Which actions does the registere
nurse (RN) delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) - answer>> -Keep the
client's skin dry
-Obtain a pressure-relieving mattress
-Turn the client every 2 hours
A nurse on the postoperative unit administers many opioid analgesics. What actions by the nurse are best to
prevent unwanted sedation as a complication of these medications? (Select all that apply.) - answer>> -Avoid
using other medications that cause sedation.
