NUR 2502 Multidimensional
Care III Exam 2 – 2025
Verified Questions &
Rationales
Question 1:
A nurse is caring for a client post-appendectomy who reports sudden severe
abdominal pain and rigidity. Vital signs show a temperature of 101.3°F (38.5°C),
heart rate 110 bpm, and blood pressure 100/60 mm Hg. What is the nurse's priority
action?
A. Administer an antipyretic medication. B. Encourage oral intake to prevent
dehydration. C. Notify the surgeon of possible peritonitis. D. Apply a warm
compress to the abdomen.
C. Notify the surgeon of possible peritonitis.
Rationale: Sudden severe pain, rigidity, fever, tachycardia, and hypotension
indicate peritonitis, a life-threatening complication of appendectomy requiring
immediate surgical intervention (e.g., drainage). Prioritization per ABCs and
Maslow's hierarchy focuses on p hysiological threats; antipyretics or compresses
delay care, and oral intake risks perforation (Potter & Perry, 2025; med -surg
emergency protocols).
Question 2:
A client with type 2 diabetes is admitted with hyperglycemia (blood glucose 350
mg/dL) and is started on IV regular insulin. The nurse should monitor for which
complication?
A. Hypoglycemia during insulin infusion. B. Hyperkalemia from fluid overload. C.
Hypomagnesemia from diuresis. D. Hypernatremia from dehydration.
A. Hypoglycemia during insulin infusion.
,Rationale: Rapid-acting regular insulin lowers blood glucose quickly, risking
hypoglycemia (blood glucose <70 mg/dL) if not titrated with hourly checks and
D5W infusion; this is a key safety priority in hyperglycemic crises (ADA
Standards, 2025). Electrolyte shifts occur, but hypoglycemia is immediate and life-
threatening, requiring protocol-driven monitoring.
Question 3:
A nurse is assessing a client with chronic kidney disease (CKD) who has a serum
potassium level of 6.2 mEq/L. Which symptom is most indicative of
hyperkalemia?
A. Muscle weakness and paresthesia. B. Polyuria and polydipsia. C. Bounding
pulses and hypertension. D. Dry mouth and thirst.
A. Muscle weakness and paresthesia.
Rationale: Hyperkalemia (>5.0 mEq/L) disrupts neuromuscular function via
depolarization block, causing flaccid weakness and tingling (early ECG peaked T-
waves progress to arrhythmias); urgent intervention (e.g., calcium gluconate) is
needed (Ignatavicius, 2025; fluid/electrolyte imbalance chapter). Other options
relate to hypo or unrelated conditions.
Question 4:
A client post-CABG surgery develops atrial fibrillation with a heart rate of 140
bpm. The nurse anticipates administration of which medication?
A. Digoxin 0.5 mg IV. B. Metoprolol 5 mg IV. C. Amiodarone 150 mg IV. D.
Lidocaine 100 mg IV.
B. Metoprolol 5 mg IV.
Rationale: Beta-blockers like metoprolol slow AV conduction and reduce ectopic
foci in post-cardiac surgery AF, controlling rate (target 60-100 bpm) per
AHA/ACC guidelines (2025); digoxin is for refractory cases, amiodarone for
rhythm, lidocaine for ventricular. Monitor BP to avoid hypotension.
Question 5:
, A nurse is educating a client with COPD about pursed-lip breathing. The primary
purpose is to:
A. Increase oxygen saturation. B. Prolong exhalation to prevent air trapping. C.
Strengthen abdominal muscles. D. Reduce inspiratory effort.
B. Prolong exhalation to prevent air trapping.
Rationale: Pursed-lip breathing creates backpressure, improving exhalation time
and reducing dynamic hyperinflation in COPD by preventing small airway
collapse (GOLD guidelines, 2025); this enhances gas exchange and reduces
dyspnea without increasing O2 demand.
Question 6:
A client with hyponatremia (Na+ 128 mEq/L) is symptomatic with confusion. The
nurse expects:
A. 3% saline infusion at 1 mL/kg/hr. B. Oral hypotonic fluids. C. Loop diuretics.
D. Demeclocycline.
A. 3% saline infusion at 1 mL/kg/hr.
Rationale: Symptomatic acute hyponatremia requires hypertonic saline to raise
Na+ 4-6 mEq/L rapidly (target <8 mEq/24hr to avoid ODS), per European Society
of Endocrinology guidelines (2025); monitor q2hr, stop at 130 mEq/L.
Question 7:
A nurse is monitoring a client after a STEMI treated with thrombolytics. Which
finding requires immediate intervention?
A. BP 110/70 mm Hg. B. HR 88 bpm. C. Gums oozing during oral care. D. Urine
output 30 mL/hr.
C. Gums oozing during oral care.
Rationale: Thrombolytics (e.g., alteplase) increase bleeding risk via plasminogen
activation; minor bleeds like gingival oozing signal potential hemorrhage,
requiring protamine or factor VIIa reversal (AHA STEMI guidelines, 2025).
Others are stable post-MI parameters.
Care III Exam 2 – 2025
Verified Questions &
Rationales
Question 1:
A nurse is caring for a client post-appendectomy who reports sudden severe
abdominal pain and rigidity. Vital signs show a temperature of 101.3°F (38.5°C),
heart rate 110 bpm, and blood pressure 100/60 mm Hg. What is the nurse's priority
action?
A. Administer an antipyretic medication. B. Encourage oral intake to prevent
dehydration. C. Notify the surgeon of possible peritonitis. D. Apply a warm
compress to the abdomen.
C. Notify the surgeon of possible peritonitis.
Rationale: Sudden severe pain, rigidity, fever, tachycardia, and hypotension
indicate peritonitis, a life-threatening complication of appendectomy requiring
immediate surgical intervention (e.g., drainage). Prioritization per ABCs and
Maslow's hierarchy focuses on p hysiological threats; antipyretics or compresses
delay care, and oral intake risks perforation (Potter & Perry, 2025; med -surg
emergency protocols).
Question 2:
A client with type 2 diabetes is admitted with hyperglycemia (blood glucose 350
mg/dL) and is started on IV regular insulin. The nurse should monitor for which
complication?
A. Hypoglycemia during insulin infusion. B. Hyperkalemia from fluid overload. C.
Hypomagnesemia from diuresis. D. Hypernatremia from dehydration.
A. Hypoglycemia during insulin infusion.
,Rationale: Rapid-acting regular insulin lowers blood glucose quickly, risking
hypoglycemia (blood glucose <70 mg/dL) if not titrated with hourly checks and
D5W infusion; this is a key safety priority in hyperglycemic crises (ADA
Standards, 2025). Electrolyte shifts occur, but hypoglycemia is immediate and life-
threatening, requiring protocol-driven monitoring.
Question 3:
A nurse is assessing a client with chronic kidney disease (CKD) who has a serum
potassium level of 6.2 mEq/L. Which symptom is most indicative of
hyperkalemia?
A. Muscle weakness and paresthesia. B. Polyuria and polydipsia. C. Bounding
pulses and hypertension. D. Dry mouth and thirst.
A. Muscle weakness and paresthesia.
Rationale: Hyperkalemia (>5.0 mEq/L) disrupts neuromuscular function via
depolarization block, causing flaccid weakness and tingling (early ECG peaked T-
waves progress to arrhythmias); urgent intervention (e.g., calcium gluconate) is
needed (Ignatavicius, 2025; fluid/electrolyte imbalance chapter). Other options
relate to hypo or unrelated conditions.
Question 4:
A client post-CABG surgery develops atrial fibrillation with a heart rate of 140
bpm. The nurse anticipates administration of which medication?
A. Digoxin 0.5 mg IV. B. Metoprolol 5 mg IV. C. Amiodarone 150 mg IV. D.
Lidocaine 100 mg IV.
B. Metoprolol 5 mg IV.
Rationale: Beta-blockers like metoprolol slow AV conduction and reduce ectopic
foci in post-cardiac surgery AF, controlling rate (target 60-100 bpm) per
AHA/ACC guidelines (2025); digoxin is for refractory cases, amiodarone for
rhythm, lidocaine for ventricular. Monitor BP to avoid hypotension.
Question 5:
, A nurse is educating a client with COPD about pursed-lip breathing. The primary
purpose is to:
A. Increase oxygen saturation. B. Prolong exhalation to prevent air trapping. C.
Strengthen abdominal muscles. D. Reduce inspiratory effort.
B. Prolong exhalation to prevent air trapping.
Rationale: Pursed-lip breathing creates backpressure, improving exhalation time
and reducing dynamic hyperinflation in COPD by preventing small airway
collapse (GOLD guidelines, 2025); this enhances gas exchange and reduces
dyspnea without increasing O2 demand.
Question 6:
A client with hyponatremia (Na+ 128 mEq/L) is symptomatic with confusion. The
nurse expects:
A. 3% saline infusion at 1 mL/kg/hr. B. Oral hypotonic fluids. C. Loop diuretics.
D. Demeclocycline.
A. 3% saline infusion at 1 mL/kg/hr.
Rationale: Symptomatic acute hyponatremia requires hypertonic saline to raise
Na+ 4-6 mEq/L rapidly (target <8 mEq/24hr to avoid ODS), per European Society
of Endocrinology guidelines (2025); monitor q2hr, stop at 130 mEq/L.
Question 7:
A nurse is monitoring a client after a STEMI treated with thrombolytics. Which
finding requires immediate intervention?
A. BP 110/70 mm Hg. B. HR 88 bpm. C. Gums oozing during oral care. D. Urine
output 30 mL/hr.
C. Gums oozing during oral care.
Rationale: Thrombolytics (e.g., alteplase) increase bleeding risk via plasminogen
activation; minor bleeds like gingival oozing signal potential hemorrhage,
requiring protamine or factor VIIa reversal (AHA STEMI guidelines, 2025).
Others are stable post-MI parameters.
