Exam 2: NUR2502/ NUR 2502 (New 2023/ 2024 Update) Multidimensional Care III/ MDC 3 Exam| Complete Guide with Questions and Verified Answers| 100% Correct – Rasmussen
Exam 2: NUR2502/ NUR 2502 (New 2023/
2024 Update) Multidimensional Care III/
MDC 3 Exam| Complete Guide with
Questions and Verified Answers| 100%
Correct – Rasmussen
QUESTION
The nurse recognizes that a patient with sleep apnea may benefit from which intervention(s)?
(Select all that apply.)
A.Weight loss
B.Nasal mask to deliver BiPAP
C.A change in sleeping position
D.Medication to increase daytime sleepiness
E.Position-fixing device that prevents tongue subluxation
Answer:
ANS: A, B, C, E
All interventions listed are viable interventions that can be of benefit to patients who have sleep
apnea. Patients should work with their providers of care to determine the severity of their sleep
apnea and which specific interventions would be of most importance to them. Encouraging
daytime sleepiness is the opposite of the effect needed for this patient.
What are the signs of sleep apea/who is at risk? Overweight, large neck size, short neckObesity
Oropharyngeal edema
Family history
Hypothyroidism
short neck with recessed chin
Enlarged tonsils, adenoids, uvula
Cigarette smoking and alcohol or sedative use
Complications: HTN
Stroke
Cognitive deficits
Weight gain
Diabetes
Pulmonary disease
Cardiovascular disease
Excessive daytime sleepiness, irritability, inability to concentrate
Treatment:Lose weight if sleep apnea is caused by obesity
Refrain from alcohol or sedatives
Avoid sleeping on your back (position fixing)
Noninvasive positive-pressure ventilation (NPPV)
QUESTION
With which client does the nurse anticipate complications from obstructive sleep apnea
following abdominal surgery?
A. 28-year-old who is 80 lbs (36.4 kg) overweight and has a short neck
B. 48-year-old who has type 1 diabetes and chronic sinusitis
C. 58-year-old who has had gastroesophageal reflux disease for 10 years
D. 78-year-old who wears upper and lower dentures and has asthma
Answer:
•A – overweight and short neck
•Age doesn’t really matter
QUESTION
Mr. Sherwood is a 27-year-old male who had a fractured nose and is recovering from a
rhinoplasty. He has a moustache dressing in place that is dry and intact. The nurse observes that
the patient is swallowing repeatedly.
What complication does the nurse anticipate? What equipment does the nurse need to assess Mr.
Sherwood?
Answer:
- Posterior nasal bleeding; penlight
•Rationale: Assessing how often the patient swallows after nasal surgery is a priority because
repeated swallowing may indicate posterior nasal bleeding. A penlight is used to examine the
throat for bleeding.
QUESTION
Mr. Sherwood is concerned because his nose keeps bleeding. He asks the nurse, “Can you tell
me again what I can do to keep my nose from bleeding?”
How should the nurse respond to Mr. Sherwood’s question?
Mr. Sherwood is discharged home. The nurse talks with him and his family on how to care for
Mr. Sherwood after discharge.
What are some talking points that the nurse should include in discharge teaching for Mr.
Sherwood and his family?
Answer:
•Answer: The nurse may suggest that the patient keep his mouth open while sneezing, not bend
over, and avoid coughing and vomiting. Avoid taking aspirin and NSAIDs while the nose heals.
Avoid straining during bowel movements.
•Rationale: These activities increase blood pressure causing fragile blood vessels to break and
bleed. Teaching the patient to avoid these activities will prevent increase in pressure. Laxatives
or stool softeners may help to ease bowel movements. Aspirin and NSAIDs increase bleeding
potential.
•
•The nurse may include instructing the patient to stay in a semi-Fowlers’ position, to move
slowly, to keep all follow-up appointments, to call his provider if fever develops, and to use a
humidifier.
•Rationale: Providing discharge instructions to Mr. Sherwood and his family allows them to be
involved in his care and increases compliance and health care outcomes. Correct positioning and
moving slowly decrease chances of bleeding and edema to the area. Following up with the
provider allows opportunity for extension of care to complete recovery and identification of
problems early.
QUESTION
Asthma occurs in two ways:
Answer:
•Inflammation
•Airway hyperresponsiveness leading to bronchoconstriction
Asthma is classified based on how well controlled the symptoms are and the patient’s response to
the medications to treat the disease process. Status asthmaticus is a severe life-threatening
condition that requires prompt intervention
QUESTION
Pathophysiology of asthma
Answer:
•Intermittent and reversible airflow obstruction affecting airways only, not alveoli
Airway obstruction
•Inflammation
•Airway hyperresponsiveness
QUESTION
causes of asthma
Answer:
exposure to allergens or irritants; stress, cold, and exercise
QUESTION
Interprofessional Collaborative Care for asthma
Answer:
Assessment: Noticing
•Physical assessment/clinical manifestations
•Audible wheeze, increased respiratory rate
•Increased cough
•Use of accessory muscles
•”Barrel chest” from air trapping
•Long breathing cycle
•Cyanosis
•Hypoxemia
Symptoms- labored breathing, wheezing, trouble sleeping, frequent cough, feeling tired, feeling
short of breath
Common triggers – pollution, dust, smoke, pet dandner, household chemicals, bacteria, viruses,
mold
QUESTION
Assessment: Noticing for asthma
Answer:
Laboratory assessment
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•Check the client’s gag reflex.
The nurse is caring for a client who just had an esophagogastroduodenoscopy (EGD) completed. The client tells the nurse that her mouth is very dry after the procedure. Which is the nurse’s best action?
•Absence of bowel movements
The clinic nurse reviews the record of a three-day-old infant and notes that the health care provider has documented a diagnosis of suspected Hirschsprung’s disease. The nurse reviews the assessment findings documented in the record, knowing that which symptom is most likely led the mother to seek health care for the infant?
•Preventing aspiration
A client has esophageal cancer. Which intervention by the nurse takes priority?
•Client takes naproxen sodium (Naprosyn) 1500 mg daily for arthritis pain.
The nurse us caring for a client who is at risk for developing gastritis. Which finding from the client’s history leads the nurse to this conclusion?
•Check the client’s blood sugar level.
The nurse is caring for a client who recently has undergone a partial gastrectomy. Two hours after eating lunch, the client becomes dizzy, diaphoretic, and confused. Which is the nurse’s priority action?
- “Do not use deodorant on breasts or underarms before the test.”
The nurse is preparing a teaching plan for a client who is scheduled to undergo mammography for the first time. What instruction by the nurse is accurate?
•”I will elevate my arm on a pillow at night.”
A client is experiencing lymphedema in the arm on the operative side after a modified radical mastectomy. Which statement indicates correct understanding of managing this problem?
•These results may indicate prostate cancer. He should be further evaluated.
A client’s laboratory findings reveal a high prostate-specific antigen level. How does the nurse interpret this information?
•”It compresses the urethra, blocking the flow of urine.”
A client with BPH asks why his enlarged prostate is causing difficulty with urination. Which is the nurse’s most accurate response?
Gloves should be worn whenever direct contact with the client’s skin is required.
A client has syphilis with sores present. What precautions are necessary for the nurse to take when caring for this client?
•Malaise
A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assessment finding?
•Bleeding esophageal varices
A client is admitted with end-stage cirrhosis and severe vomiting. Which problem should the nurse monitor the client most carefully for?
•Clay-colored stools
The nurse monitors for which clinical manifestation in a client with a decreased fecal urobilinogen concentration?
•Maintaining NPO status for the client with IV fluids
The nurse is caring for a client with acute pancreatitis. Which nursing intervention best reduces discomfort for the client?
•BMI > 30
The nurse assesses the client with cystic fibrosis for all of the following clinical manifestations associated with this disease except:
•Keep wire cutters readily available at all times.
Which of the following is a priority education for a client who is being discharged after surgical intervention for a mandibular fracture?
•Heart rate 120 beats/minute
The nurse is getting ready to administer Albuterol inhaler. Which of the following symptoms might indicate a need to contact the healthcare provider before administering this medication?
•10 seconds
•The nurse is preparing to suction a client via a tracheostomy tube. The nurse should plan to limit the suctioning time to a maximum of which time period?
Pain, especially with inspiration
•The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding?
•Mask
The nurse is taking the history of a client with occupational lung disease (silicosis). The nurse should assess whether the client wears which item during periods of exposure to silica particles?
•Stagnation
You are taking care of 50-year-old client who seems frustrated. He resents his younger counterparts, associates with his family to meet his needs, and is not interested in volunteering in community events. This client is likely experiencing
•Cloudy CSF, elevated protein
A lumbar puncture is performed on a client suspected to have bacterial meningitis, and cerebrospinal fluid (CSF) is obtained for analysis. The nurse reviews the results of the CSF analysis and determines that which results would verify the diagnosis?
•Take medications 45 minutes to one hour before meals
The nurse should instruct the client with myasthenia gravis to
•Supine with HOB 30 degrees
The nurse is caring for a client who has undergone a craniotomy and has a supratentorial incision. The nurse should place the client in which position postoperatively?
•The client is coughing pink, frothy sputum
The nurse is taking care of a client who has experienced a myocardial infarction (MI). The health care provider should be notified when the nurse notes which finding?
Chest discomfort when walking and subsiding with rest
The nurse is taking the history of a client with suspected coronary artery disease (CAD). Which situation correlates with stable angina?
•Systolic murmur
The nurse is caring for a client diagnosed with aortic stenosis. What assessment finding does the nurse expect in this client?
S3 sound
A nurse is assessing a patient with heart failure and auscultates a heart sound right after the second heart sound. How will the nurse document this heart sound?
. I will give my canned soups to the food pantry
The nurse is caring for a client with newly diagnosed hypertension. What statement by the client indicates adequate understanding of his or her diet restrictions?
•Wear warm clothing when exposed to cool temperatures
The nurse is providing disease management education to a client with Raynaud’s disease. What intervention does the nurse suggest to prevent complications if this disease?
Serum amylase, 200 U/L
A 68-year-old patient presents to the ED the day after Thanksgiving, stating that he has “eaten and drunk quite a bit.” He states that about 1 hour ago he experienced a sudden onset of pain in the left upper quadrant that radiates to his left flank. He rates the pain as an 8 on a 0-to-10 scale. The patient is admitted with acute pancreatitis.
Pleural effusion
Diabetes mellitus
Pancreatic infection
Acute kidney failure
In preparing to care for the patient, which conditions does the nurse recognize as potential complications of acute pancreatitis? (Select all that apply.)
PCA morphine sulfate
When the patient is asked about pain, he says that it is intense and continuous. He states that sometimes when he curls up in a fetal position the pain eases.
Which medication does the nurse recognize that will provide the most comprehensive pain relief at this time?
Small and frequent meals are best.
The patient has been NPO but is now tolerating food.
What education will the nurse provide regarding nutrition?
Administer oxygen via Venturi mask
A patient with a history of chronic obstructive pulmonary disease is admitted with shortness of breath. Which nursing intervention is most appropriate?
Tracheomalacia
The nurse is caring for a patient with a cuffed tracheostomy and is aware the patient is at risk for developing which complication?
Oxygenate the patient with 100% oxygen
While suctioning a patient, vagal stimulation occurs. What is the appropriate nursing action?
Encourage the patient to sit in a chair for meals.
The nurse is caring for a patient admitted for treatment of neck and throat cancer. Which intervention should the nurse perform?
Clear glucose positive fluid draining from nares
The nurse is caring for a patient admitted to the ED after experiencing a fall while rock climbing. The patient has several facial fractures. Which objective assessment finding requires immediate intervention?
Weight loss
Nasal mask to deliver BiPAP
A change in sleeping position
Position-fixing device that prevents tongue subluxation
The nurse recognizes that a patient with sleep apnea may benefit from which intervention(s)? (Select all that apply.)
Respiratory rate
The patient is assessed and a blood glucose level and vital signs are obtained upon arrival on the unit. Results are as follows:
BG—239 mg/dL BP—138/88 mm Hg
HR—128 RR—36 breaths/min
O2 saturation—88% (room air) Temperature—101.6º F
Which vital sign or test result requires the nurse’s immediate attention?
Oxygen at 2 L per nasal cannula
After consulting with the provider, the following orders are received:
Full liquid diabetic diet
IV fluids 1000 mL .9 NS at 60 mL/hr
Oxygen at 2 L per nasal cannula
Blood cultures × 3 and urinalysis
Tylenol grain × every 4 hour for temperature above 101º F
Cefazolin (Ancef) 1 g IVP every 8 hour
Prolonged immobility; advancing age; recent surgery.
A 65-year-old woman is brought to the ED by her husband with new-onset shortness of breath. She had an abdominal hysterectomy 5 days ago. Her husband states that she stayed in bed since she was discharged from her surgery 48 hours ago, because she feels very short of breath when she gets up.
What risk factors are present for VTE?
The patient may have a pulmonary embolism. She could also have pneumonia based on her recent surgery and immobility. Further assessment should be performed to ascertain the specifics of her symptoms.
During triage, the following vital signs and assessments are noted
Temperature—99.6º F BP—80/44 mm Hg
P—126 (sinus tachycardia) R—28 and labored
O2 saturation—84% (room air) Crackles bilaterally
Petechiae across chest and in axillae
Based on these findings, what do you suspect might be happening with the patient?
Place the patient on a bedpan and stay with her until she is finished.
While in the treatment room, the patient says she needs to use the bathroom. The nurse delegates this task to the unlicensed assistive personnel (UAP).
aPTT is 1.5 to 2.5 times the control.
Two hours later, the patient is admitted to the medical unit where she is started on a continuous IV heparin weight-based protocol.
Which finding indicates that the heparin infusion is therapeutic?
-“Be sure to have follow-up INR laboratory tests done.”
-“Report any bruising or bleeding to your provider.”
-.”Use a soft toothbrush to brush your teeth and an electric razor to shave your legs.”
Three days later, the provider prepares to discharge the patient on warfarin (Coumadin).
Which teaching points do you include about this therapy? (Select all that apply.)
A.Triglycerides 168 mg/dL
B.HDLs 40 mg/dL
A patient has recently been admitted with a diagnosis of coronary artery disease. What lab assessments would the nurse anticipate? (Select all that apply.)
Ask the patient to lay on his left side.
The nurse is assessing a patient’s heart sounds and has difficulty auscultating the first heart sound, S1. Which nursing response is most appropriate?
“Smoking is a major risk factor for coronary artery disease and peripheral vascular disease.”
A patient who smokes asks the nurse, “Smoking just hurts my lungs, not my heart, right?” Which nursing response is appropriate?
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