COMPREHENSIVE NURSING CAPSTONE EXAM 2 STUDY GUIDE
QUESTION AND ANSWERS | VERIFIED AND WELL DETAILED
ANSWERS | PLUS RATIONALES | GUARANTEED PASS | LATEST
EXAM UPDATE | EXAM PREP | STUDY GUIDE | PRACTICE TEST
1. A nurse is caring for a postoperative client who underwent a total knee arthroplasty 6
hours ago. The client reports a pain level of 8 out of 10 on a numeric rating scale. Vital
signs are stable, but the client appears tense and reluctant to move. Which nursing action is
most appropriate?
A. Administer the prescribed PRN opioid analgesic and reassess pain within 30 minutes.
B. Encourage the client to use deep breathing exercises and distraction instead of medication.
C. Contact the primary healthcare provider immediately to request a change in the surgical
procedure.
D. Document the pain score and advise the client that pain is an expected part of recovery.
The nurse must prioritize effective pain management to facilitate early ambulation and
prevent complications such as deep vein thrombosis. Administering prescribed analgesics
promptly addresses acute postoperative pain, while reassessment evaluates intervention
efficacy. Relying solely on non-pharmacological methods is insufficient for severe acute pain,
and dismissing the client's pain violates professional care standards.
2. A charge nurse is evaluating the shift assignments for a medical-surgical unit. Which
client should be assigned to an experienced registered nurse rather than a licensed
practical nurse?
A. A client with chronic obstructive pulmonary disease requiring routine oral medication
administration.
B. A client newly admitted with diabetic ketoacidosis receiving an intravenous insulin
infusion.
C. A client with a stage 2 pressure ulcer requiring a routine dry gauze dressing change.
D. A client diagnosed with stable heart failure requiring assistance with morning hygiene.
Managing a client with diabetic ketoacidosis on an intravenous insulin infusion requires
continuous hemodynamic and metabolic monitoring, complex titration, and advanced clinical
judgment that falls within the registered nurse scope of practice. The other scenarios involve
stable clients or predictable, routine care tasks appropriate for a licensed practical nurse or
assistive personnel.
,3. An emergency department nurse receives a client who sustained multiple traumatic
injuries in a motor vehicle collision. The client is restless, pale, and diaphoretic with a blood
pressure of 88/50 mmHg and a heart rate of 128 beats per minute. Which initial nursing
intervention is critical?
A. Insert an indwelling urinary catheter and record hourly urine output.
B. Initiate two large-bore peripheral intravenous lines for rapid fluid resuscitation.
C. Prepare the client for an immediate diagnostic magnetic resonance imaging scan.
D. Administer oral rehydration solutions to restore circulating blood volume.
The client exhibits classic signs of hypovolemic shock resulting from acute blood loss.
Establishing rapid vascular access with two large-bore intravenous lines is essential for the
immediate infusion of isotonic crystalloids and blood products to restore perfusion. Oral
intake is contraindicated due to potential surgical intervention and altered mental status, and
diagnostic imaging must wait until hemodynamic stabilization is achieved.
4. A nurse is providing discharge instructions to a client with a newly prescribed regimen
of warfarin for atrial fibrillation. Which statement by the client indicates a need for further
education?
A. I will use a soft-bristled toothbrush and an electric razor to prevent bleeding.
B. I should maintain a consistent intake of foods rich in vitamin K, such as spinach and kale.
C. I can safely take high doses of over-the-counter aspirin daily for minor joint aches.
D. I will keep my scheduled appointments for routine blood testing to check my international
normalized ratio.
Aspirin and other nonsteroidal anti-inflammatory drugs increase the risk of severe bleeding
when taken concurrently with anticoagulants like warfarin. The client must be instructed to
avoid these medications unless specifically prescribed by the provider. The other statements
demonstrate correct understanding regarding safe living practices, dietary consistency with
vitamin K, and laboratory monitoring.
5. A nurse enters the room of a client receiving mechanical ventilation and notes that the
low-pressure alarm is sounding continuously. What is the immediate priority action for the
nurse?
A. Check the ventilator tubing for a disconnection or leak.
B. Suction the endotracheal tube immediately to clear thick secretions.
, C. Silence the alarm permanently to decrease client anxiety.
D. Disconnect the client from the ventilator and initiate manual bag-valve ventilation.
A low-pressure alarm typically indicates a loss of circuit integrity, such as a disconnected tube,
displaced artificial airway, or loose connection. The nurse must quickly inspect the entire
circuit to identify and resolve the disconnection. Suctioning addresses high-pressure alarms
caused by obstruction, and silencing alarms without troubleshooting compromises client
safety.
6. A public health nurse is reviewing immunization records at a community pediatric clinic.
Which vaccine is contraindicated for an infant who is severely immunocompromised?
A. Inactivated poliovirus vaccine
B. Measles, mumps, and rubella vaccine
C. Haemophilus influenzae type b conjugate vaccine
D. Diphtheria, tetanus, and acellular pertussis vaccine
The measles, mumps, and rubella vaccine is a live attenuated viral vaccine and is strictly
contraindicated in individuals with severe immunosuppression due to the risk of causing a
disseminated, life-threatening infection. Inactivated and conjugate vaccines do not contain
live organisms and can be administered safely depending on specific medical guidance.
7. A nurse is assessing an older adult client who was admitted with a diagnosis of bacterial
pneumonia. Which clinical manifestation is most indicative of pneumonia in this
demographic?
A. High-grade fever and productive cough with rust-colored sputum
B. Acute confusion and sudden decline in functional status
C. Severe pleuritic chest pain localized to the right lower lobe
D. Intermittent wheezing heard primarily during forced expiration
Older adult clients frequently present with atypical symptoms of infection, such as acute
confusion, lethargy, or a sudden change in mental status, often in the absence of classic signs
like high fever or localized chest pain. Recognizing these subtle indicators ensures timely
diagnosis and treatment in vulnerable populations.
8. A nurse is preparing to administer a unit of packed red blood cells to a client with
chronic anemia. Which action is mandatory immediately prior to initiating the
transfusion?
QUESTION AND ANSWERS | VERIFIED AND WELL DETAILED
ANSWERS | PLUS RATIONALES | GUARANTEED PASS | LATEST
EXAM UPDATE | EXAM PREP | STUDY GUIDE | PRACTICE TEST
1. A nurse is caring for a postoperative client who underwent a total knee arthroplasty 6
hours ago. The client reports a pain level of 8 out of 10 on a numeric rating scale. Vital
signs are stable, but the client appears tense and reluctant to move. Which nursing action is
most appropriate?
A. Administer the prescribed PRN opioid analgesic and reassess pain within 30 minutes.
B. Encourage the client to use deep breathing exercises and distraction instead of medication.
C. Contact the primary healthcare provider immediately to request a change in the surgical
procedure.
D. Document the pain score and advise the client that pain is an expected part of recovery.
The nurse must prioritize effective pain management to facilitate early ambulation and
prevent complications such as deep vein thrombosis. Administering prescribed analgesics
promptly addresses acute postoperative pain, while reassessment evaluates intervention
efficacy. Relying solely on non-pharmacological methods is insufficient for severe acute pain,
and dismissing the client's pain violates professional care standards.
2. A charge nurse is evaluating the shift assignments for a medical-surgical unit. Which
client should be assigned to an experienced registered nurse rather than a licensed
practical nurse?
A. A client with chronic obstructive pulmonary disease requiring routine oral medication
administration.
B. A client newly admitted with diabetic ketoacidosis receiving an intravenous insulin
infusion.
C. A client with a stage 2 pressure ulcer requiring a routine dry gauze dressing change.
D. A client diagnosed with stable heart failure requiring assistance with morning hygiene.
Managing a client with diabetic ketoacidosis on an intravenous insulin infusion requires
continuous hemodynamic and metabolic monitoring, complex titration, and advanced clinical
judgment that falls within the registered nurse scope of practice. The other scenarios involve
stable clients or predictable, routine care tasks appropriate for a licensed practical nurse or
assistive personnel.
,3. An emergency department nurse receives a client who sustained multiple traumatic
injuries in a motor vehicle collision. The client is restless, pale, and diaphoretic with a blood
pressure of 88/50 mmHg and a heart rate of 128 beats per minute. Which initial nursing
intervention is critical?
A. Insert an indwelling urinary catheter and record hourly urine output.
B. Initiate two large-bore peripheral intravenous lines for rapid fluid resuscitation.
C. Prepare the client for an immediate diagnostic magnetic resonance imaging scan.
D. Administer oral rehydration solutions to restore circulating blood volume.
The client exhibits classic signs of hypovolemic shock resulting from acute blood loss.
Establishing rapid vascular access with two large-bore intravenous lines is essential for the
immediate infusion of isotonic crystalloids and blood products to restore perfusion. Oral
intake is contraindicated due to potential surgical intervention and altered mental status, and
diagnostic imaging must wait until hemodynamic stabilization is achieved.
4. A nurse is providing discharge instructions to a client with a newly prescribed regimen
of warfarin for atrial fibrillation. Which statement by the client indicates a need for further
education?
A. I will use a soft-bristled toothbrush and an electric razor to prevent bleeding.
B. I should maintain a consistent intake of foods rich in vitamin K, such as spinach and kale.
C. I can safely take high doses of over-the-counter aspirin daily for minor joint aches.
D. I will keep my scheduled appointments for routine blood testing to check my international
normalized ratio.
Aspirin and other nonsteroidal anti-inflammatory drugs increase the risk of severe bleeding
when taken concurrently with anticoagulants like warfarin. The client must be instructed to
avoid these medications unless specifically prescribed by the provider. The other statements
demonstrate correct understanding regarding safe living practices, dietary consistency with
vitamin K, and laboratory monitoring.
5. A nurse enters the room of a client receiving mechanical ventilation and notes that the
low-pressure alarm is sounding continuously. What is the immediate priority action for the
nurse?
A. Check the ventilator tubing for a disconnection or leak.
B. Suction the endotracheal tube immediately to clear thick secretions.
, C. Silence the alarm permanently to decrease client anxiety.
D. Disconnect the client from the ventilator and initiate manual bag-valve ventilation.
A low-pressure alarm typically indicates a loss of circuit integrity, such as a disconnected tube,
displaced artificial airway, or loose connection. The nurse must quickly inspect the entire
circuit to identify and resolve the disconnection. Suctioning addresses high-pressure alarms
caused by obstruction, and silencing alarms without troubleshooting compromises client
safety.
6. A public health nurse is reviewing immunization records at a community pediatric clinic.
Which vaccine is contraindicated for an infant who is severely immunocompromised?
A. Inactivated poliovirus vaccine
B. Measles, mumps, and rubella vaccine
C. Haemophilus influenzae type b conjugate vaccine
D. Diphtheria, tetanus, and acellular pertussis vaccine
The measles, mumps, and rubella vaccine is a live attenuated viral vaccine and is strictly
contraindicated in individuals with severe immunosuppression due to the risk of causing a
disseminated, life-threatening infection. Inactivated and conjugate vaccines do not contain
live organisms and can be administered safely depending on specific medical guidance.
7. A nurse is assessing an older adult client who was admitted with a diagnosis of bacterial
pneumonia. Which clinical manifestation is most indicative of pneumonia in this
demographic?
A. High-grade fever and productive cough with rust-colored sputum
B. Acute confusion and sudden decline in functional status
C. Severe pleuritic chest pain localized to the right lower lobe
D. Intermittent wheezing heard primarily during forced expiration
Older adult clients frequently present with atypical symptoms of infection, such as acute
confusion, lethargy, or a sudden change in mental status, often in the absence of classic signs
like high fever or localized chest pain. Recognizing these subtle indicators ensures timely
diagnosis and treatment in vulnerable populations.
8. A nurse is preparing to administer a unit of packed red blood cells to a client with
chronic anemia. Which action is mandatory immediately prior to initiating the
transfusion?
