MDC4 Exam 1 Rasmussen
1. A nurse is administering blood to a client with acute blood loss. Which action should the nurse take
if the client experiences chills, back pain, and shortness of breath?
A. Continue the infusion at a slower rate
B. Stop the transfusion immediately and notify the physician
C. Administer acetaminophen and reassess
D. Increase the infusion rate to resolve the symptoms
2. A client is receiving IV heparin therapy for deep vein thrombosis. Which laboratory value indicates
the therapy is effective?
A. Hemoglobin of 12.5 g/dL
B. aPTT of 65 seconds
C. Platelet count of 200,000/mm³
D. INR of 1.0
3. A client with heart failure is receiving digoxin. The nurse should withhold the medication if the
client exhibits which of the following?
A. Heart rate of 50 beats per minute
B. Respiratory rate of 20 breaths per minute
C. Blood pressure of 130/80 mmHg
D. Oxygen saturation of 92%
4. Which of the following is the priority intervention for a client experiencing a hypertensive crisis?
A. Encourage the client to rest in a quiet room
B. Administer antihypertensive medications via IV as ordered
C. Place the client in the Trendelenburg position
D. Measure the client’s blood pressure every 4 hours
5. A nurse is caring for a client post-op following a thyroidectomy. Which of the following findings
should alert the nurse to potential thyroid storm?
A. Bradycardia and hypotension
B. Tachycardia and hyperthermia
C. Cold intolerance and fatigue
D. Weight gain and depression
,6. A client with diabetes mellitus is brought to the emergency department with confusion and
diaphoresis. Which of the following is the nurse’s priority action?
A. Administer 50% dextrose intravenously
B. Check the client's urine for ketones
C. Give the client 8 oz of orange juice
D. Notify the healthcare provider
7. A client diagnosed with cirrhosis has ascites. Which dietary modification should the nurse include in
the plan of care?
A. Increase protein intake
B. Encourage fluid intake
C. Restrict sodium intake
D. Decrease carbohydrate intake
8. Case Scenario:
Ms. Thompson, a 70-year-old female, is admitted to the emergency department with sudden onset of
right-sided weakness and slurred speech. Her past medical history includes hypertension and atrial
fibrillation. A CT scan confirms an ischemic stroke.
Questions:
1. Which of the following is the priority action for the nurse to take?
o A. Assess the time of symptom onset.
o B. Prepare the client for a lumbar puncture.
o C. Perform a neurological assessment.
o D. Start IV fluids at a rapid rate.
2. Ms. Thompson's husband reports that her symptoms began 2 hours ago. The nurse anticipates
that the provider will order which of the following treatments?
o A. Anticoagulants
o B. Thrombolytic therapy (tPA)
o C. Antiplatelet therapy
o D. Antihypertensive medications
3. Which assessment finding indicates that Ms. Thompson is at risk for aspiration?
o A. Slurred speech
o B. Bilateral lung crackles
, o C. Muscle weakness
o D. Increased respiratory rate
4. After stabilizing, the nurse includes which of the following interventions in Ms. Thompson's
care plan to prevent future strokes?
o A. Administer daily aspirin therapy.
o B. Implement a low-protein diet.
o C. Advise smoking cessation.
o D. Encourage high fluid intake.
9. A nurse is assessing a client with suspected bacterial meningitis. Which of the following findings
should the nurse report to the provider immediately?
A. Positive Babinski reflex
B. Nuchal rigidity and photophobia
C. Generalized fatigue and malaise
D. Decreased appetite
10. A nurse is caring for a client with COPD who is receiving oxygen at 2 L/min via nasal cannula.
Which of the following findings indicates the client is experiencing oxygen toxicity?
A. Nausea and fatigue
B. Restlessness and confusion
C. Bradycardia and cyanosis
D. Tachypnea and tachycardia
11. A client with chronic kidney disease is prescribed epoetin alfa. Which laboratory result should the
nurse monitor to evaluate the effectiveness of this medication?
A. Creatinine level
B. Blood urea nitrogen (BUN)
C. Hemoglobin level
D. Platelet count
1. A nurse is administering blood to a client with acute blood loss. Which action should the nurse take
if the client experiences chills, back pain, and shortness of breath?
A. Continue the infusion at a slower rate
B. Stop the transfusion immediately and notify the physician
C. Administer acetaminophen and reassess
D. Increase the infusion rate to resolve the symptoms
2. A client is receiving IV heparin therapy for deep vein thrombosis. Which laboratory value indicates
the therapy is effective?
A. Hemoglobin of 12.5 g/dL
B. aPTT of 65 seconds
C. Platelet count of 200,000/mm³
D. INR of 1.0
3. A client with heart failure is receiving digoxin. The nurse should withhold the medication if the
client exhibits which of the following?
A. Heart rate of 50 beats per minute
B. Respiratory rate of 20 breaths per minute
C. Blood pressure of 130/80 mmHg
D. Oxygen saturation of 92%
4. Which of the following is the priority intervention for a client experiencing a hypertensive crisis?
A. Encourage the client to rest in a quiet room
B. Administer antihypertensive medications via IV as ordered
C. Place the client in the Trendelenburg position
D. Measure the client’s blood pressure every 4 hours
5. A nurse is caring for a client post-op following a thyroidectomy. Which of the following findings
should alert the nurse to potential thyroid storm?
A. Bradycardia and hypotension
B. Tachycardia and hyperthermia
C. Cold intolerance and fatigue
D. Weight gain and depression
,6. A client with diabetes mellitus is brought to the emergency department with confusion and
diaphoresis. Which of the following is the nurse’s priority action?
A. Administer 50% dextrose intravenously
B. Check the client's urine for ketones
C. Give the client 8 oz of orange juice
D. Notify the healthcare provider
7. A client diagnosed with cirrhosis has ascites. Which dietary modification should the nurse include in
the plan of care?
A. Increase protein intake
B. Encourage fluid intake
C. Restrict sodium intake
D. Decrease carbohydrate intake
8. Case Scenario:
Ms. Thompson, a 70-year-old female, is admitted to the emergency department with sudden onset of
right-sided weakness and slurred speech. Her past medical history includes hypertension and atrial
fibrillation. A CT scan confirms an ischemic stroke.
Questions:
1. Which of the following is the priority action for the nurse to take?
o A. Assess the time of symptom onset.
o B. Prepare the client for a lumbar puncture.
o C. Perform a neurological assessment.
o D. Start IV fluids at a rapid rate.
2. Ms. Thompson's husband reports that her symptoms began 2 hours ago. The nurse anticipates
that the provider will order which of the following treatments?
o A. Anticoagulants
o B. Thrombolytic therapy (tPA)
o C. Antiplatelet therapy
o D. Antihypertensive medications
3. Which assessment finding indicates that Ms. Thompson is at risk for aspiration?
o A. Slurred speech
o B. Bilateral lung crackles
, o C. Muscle weakness
o D. Increased respiratory rate
4. After stabilizing, the nurse includes which of the following interventions in Ms. Thompson's
care plan to prevent future strokes?
o A. Administer daily aspirin therapy.
o B. Implement a low-protein diet.
o C. Advise smoking cessation.
o D. Encourage high fluid intake.
9. A nurse is assessing a client with suspected bacterial meningitis. Which of the following findings
should the nurse report to the provider immediately?
A. Positive Babinski reflex
B. Nuchal rigidity and photophobia
C. Generalized fatigue and malaise
D. Decreased appetite
10. A nurse is caring for a client with COPD who is receiving oxygen at 2 L/min via nasal cannula.
Which of the following findings indicates the client is experiencing oxygen toxicity?
A. Nausea and fatigue
B. Restlessness and confusion
C. Bradycardia and cyanosis
D. Tachypnea and tachycardia
11. A client with chronic kidney disease is prescribed epoetin alfa. Which laboratory result should the
nurse monitor to evaluate the effectiveness of this medication?
A. Creatinine level
B. Blood urea nitrogen (BUN)
C. Hemoglobin level
D. Platelet count
