CAPSTONE B 2 LEARNING WORKBOOK 2026
CLINICAL REASONING AND EVIDENCE BASED
PRACTICE APPLICATIONS
◉ A nurse is planning care for a client who is receiving mechanical
ventilation. Which of the following actions should the nurse include
in the plan
A. Provide the client with a means of communication
B. Maintain the head of the client's bed in a flat position
C. Suction the client's endotracheal tube every 4 hr
D. Perform oral hygiene for the client every 8 hr.
Answer: A.) Provide the client with a means of communication
Use electronic tablet computer, programmable speech generating
device, alphabet board, pencil and paper, etc
◉ A nurse is caring for a client who is receiving IV fluid replacement
therapy for dehydration. Which of the following laboratory results
indicates effectiveness of the treatment
A. Sodium 165 mEq/L
,B. Potassium 5.2 mEq/L
C. Urine specific gravity 1.020
D. Hct 62%.
Answer: C Urine specific gravity 1.020
Within the expected range of 1.005-1.030
◉ A nurse is monitoring the laboratory findings for a client who is
postoperative following a total hip arthroplasty 6 hr ago. Which of
the following values indicates that the client has an increased risk
for bleeding
A. PT 11.5 seconds
B. aPTT 35 seconds
C. Platelets 80,000
D. RBC 4.0 million.
Answer: C Platelets 80,000
platelet range is 150,000-400,000
◉ A nurse is admitting a client who has a cervical spinal cord injury
following a motor vehicle crash. Which of the following
interventions is the nurse's priority while caring for this client
A. Change the client's position every 2 hours
,B. Pad pressure points at the edges of the client's cervical collar
C. Palpate the client's abdomen for bladder distention
D. Assist the client with quad coughing.
Answer: D Assist the client with quad coughing
The greatest risk to a client who has a cervical spinal cord injury is
an obstructed airway; the priority is to ensure the client can clear
their airway. Apply abdominal pressure as the client coughs (quad
coughing)
◉ A nurse is caring for a client who is receiving a blood transfusion.
Which of the following findings indicates that the client is
experiencing transfusion-associated circulatory overload
A. Nasuea
B. Hypothermia
C. Dyspnea
D. Bradycardia.
Answer: C Dyspnea
Dyspnea is an indication of possible transfusion associated
circulatory overload, leading to hypertension, bounding pulses, and
confusion. Dyspnea can also indicate transfusion related acute lung
injury to an anaphylactic response, which also causes wheezing,
chest tightness, cyanosis, and low BP
, ◉ A nurse is assessing a client who has lung cancer and is
undergoing radiation therapy to the chest. Which of the following
indicates an adverse effect of the therapy
A. Hair loss on the scalp
B. Sweating at the treatment site
C. Altered taste sensations
D. Intolerance to cold.
Answer: C Altered taste sensations
Altered taste is a result of the release of metabolites by dead cells
◉ A nurse is preparing to administer a unit of packed RBCs to a
client who has anemia. Which of the following actions should the
nurse plan to take (select all that apply)
A. Obtain pre-transfusion temperature
B. Prime the IV tubing with lactated Ringer's
C. Instruct an assistive personnel to monitor the client during the
transfusion
D. Verify the client's blood type with a second nurse
E. Use a 20 gauge IV needle for venous access.
Answer: A, D, E
A, complete assessment prior to transfusion
CLINICAL REASONING AND EVIDENCE BASED
PRACTICE APPLICATIONS
◉ A nurse is planning care for a client who is receiving mechanical
ventilation. Which of the following actions should the nurse include
in the plan
A. Provide the client with a means of communication
B. Maintain the head of the client's bed in a flat position
C. Suction the client's endotracheal tube every 4 hr
D. Perform oral hygiene for the client every 8 hr.
Answer: A.) Provide the client with a means of communication
Use electronic tablet computer, programmable speech generating
device, alphabet board, pencil and paper, etc
◉ A nurse is caring for a client who is receiving IV fluid replacement
therapy for dehydration. Which of the following laboratory results
indicates effectiveness of the treatment
A. Sodium 165 mEq/L
,B. Potassium 5.2 mEq/L
C. Urine specific gravity 1.020
D. Hct 62%.
Answer: C Urine specific gravity 1.020
Within the expected range of 1.005-1.030
◉ A nurse is monitoring the laboratory findings for a client who is
postoperative following a total hip arthroplasty 6 hr ago. Which of
the following values indicates that the client has an increased risk
for bleeding
A. PT 11.5 seconds
B. aPTT 35 seconds
C. Platelets 80,000
D. RBC 4.0 million.
Answer: C Platelets 80,000
platelet range is 150,000-400,000
◉ A nurse is admitting a client who has a cervical spinal cord injury
following a motor vehicle crash. Which of the following
interventions is the nurse's priority while caring for this client
A. Change the client's position every 2 hours
,B. Pad pressure points at the edges of the client's cervical collar
C. Palpate the client's abdomen for bladder distention
D. Assist the client with quad coughing.
Answer: D Assist the client with quad coughing
The greatest risk to a client who has a cervical spinal cord injury is
an obstructed airway; the priority is to ensure the client can clear
their airway. Apply abdominal pressure as the client coughs (quad
coughing)
◉ A nurse is caring for a client who is receiving a blood transfusion.
Which of the following findings indicates that the client is
experiencing transfusion-associated circulatory overload
A. Nasuea
B. Hypothermia
C. Dyspnea
D. Bradycardia.
Answer: C Dyspnea
Dyspnea is an indication of possible transfusion associated
circulatory overload, leading to hypertension, bounding pulses, and
confusion. Dyspnea can also indicate transfusion related acute lung
injury to an anaphylactic response, which also causes wheezing,
chest tightness, cyanosis, and low BP
, ◉ A nurse is assessing a client who has lung cancer and is
undergoing radiation therapy to the chest. Which of the following
indicates an adverse effect of the therapy
A. Hair loss on the scalp
B. Sweating at the treatment site
C. Altered taste sensations
D. Intolerance to cold.
Answer: C Altered taste sensations
Altered taste is a result of the release of metabolites by dead cells
◉ A nurse is preparing to administer a unit of packed RBCs to a
client who has anemia. Which of the following actions should the
nurse plan to take (select all that apply)
A. Obtain pre-transfusion temperature
B. Prime the IV tubing with lactated Ringer's
C. Instruct an assistive personnel to monitor the client during the
transfusion
D. Verify the client's blood type with a second nurse
E. Use a 20 gauge IV needle for venous access.
Answer: A, D, E
A, complete assessment prior to transfusion
