Nursing Capstone Comprehensive NCLEX-RN® – RN
Nursing Capstone Study Guide, Original Practice
Questions & Answers, Comprehensive NCLEX-RN®
Exam Preparation, NGN-Style Clinical Judgment,
Adult Medical-Surgical Nursing, Fundamentals,
Pharmacology, Maternal-Newborn, Pediatrics,
Mental Health, Leadership, Community Health,
Critical Care, Prioritization, Delegation, Patient
Safety, Health Assessment & Clinical Decision-
Making
Question 1: A nurse is caring for a client with a new diagnosis of syndrome of
inappropriate antidiuretic hormone (SIADH). Which of the following
laboratory findings would the nurse expect to be associated with this
condition?
A. Serum sodium 155 mEq/L and serum osmolality 310 mOsm/kg
B. Serum sodium 120 mEq/L and serum osmolality 260 mOsm/kg
C. Serum potassium 5.5 mEq/L and serum osmolality 290 mOsm/kg
D. Serum calcium 11.5 mg/dL and serum osmolality 300 mOsm/kg
CORRECT ANSWER: B. Serum sodium 120 mEq/L and serum osmolality 260
mOsm/kg
Rationale: SIADH is characterized by excessive release of antidiuretic hormone (ADH),
leading to water retention, dilutional hyponatremia, and decreased serum osmolality. A
serum sodium of 120 mEq/L (low) and an osmolality of 260 mOsm/kg (low) are
hallmark findings. Option A reflects hypernatremia and high osmolality, which are seen
in diabetes insipidus. Options C and D are incorrect as they reflect hyperkalemia and
hypercalcemia, respectively, which are not primary features of SIADH.
Question 2: A nurse is preparing to administer a blood transfusion to a client.
Which of the following actions is most important for the nurse to take to
prevent a transfusion reaction?
A. Premedicate the client with diphenhydramine
B. Verify the client's identity and blood compatibility with another licensed nurse
C. Infuse the blood over 4 hours to prevent fluid overload
D. Keep the blood refrigerated at the bedside until the start of the infusion
CORRECT ANSWER: B. Verify the client's identity and blood compatibility with
another licensed nurse
Rationale: The most critical action to prevent a hemolytic transfusion reaction is the
verification of the client's identity and blood product compatibility with another licensed
nurse. This includes checking the client's name, date of birth, blood type, Rh factor, and
,unit number against the blood bag and the medical record. While premedication (A)
may help with allergic reactions, it does not prevent ABO incompatibility. Infusion time
(C) and storage (D) are important but secondary to accurate identification.
Question 3: A client in the emergency department is exhibiting signs of
anaphylaxis after receiving intravenous penicillin. Which of the following is
the priority nursing action?
A. Administer epinephrine intramuscularly
B. Apply high-flow oxygen via a non-rebreather mask
C. Establish a second large-bore intravenous line
D. Administer intravenous diphenhydramine
CORRECT ANSWER: A. Administer epinephrine intramuscularly
Rationale: In anaphylaxis, the priority is to reverse severe vasodilation, bronchospasm,
and hypotension. Epinephrine is the first-line treatment and should be administered
intramuscularly in the anterolateral thigh. While oxygen (B), IV access (C), and
diphenhydramine (D) are important, they are secondary to the immediate
administration of epinephrine.
Question 4: A nurse is providing discharge teaching to a client with heart
failure. Which of the following client statements indicates an understanding of
dietary restrictions?
A. "I can use salt substitutes freely because they do not contain sodium."
B. "I should limit my daily fluid intake to about 2 liters."
C. "I can eat canned soups as they are low in fat."
D. "I should avoid foods high in potassium like bananas."
CORRECT ANSWER: B. "I should limit my daily fluid intake to about 2 liters."
Rationale: Clients with heart failure are typically placed on fluid restrictions (often 1.5
to 2 liters per day) and a low-sodium diet to reduce preload and cardiac workload. Salt
substitutes (A) are often high in potassium and may contain sodium, so they should be
avoided unless approved. Canned soups (C) are high in sodium. Potassium restriction
(D) is not a standard recommendation for heart failure unless hyperkalemia is present.
Question 5: A nurse is assessing a client who has a chest tube connected to a
closed-chest drainage system. Which of the following findings indicates a
possible air leak?
A. Continuous bubbling in the water seal chamber
B. Fluctuation of fluid in the water seal chamber with respirations
,C. Gentle bubbling in the suction control chamber
D. Serosanguineous drainage in the collection chamber
CORRECT ANSWER: A. Continuous bubbling in the water seal chamber
Rationale: Continuous bubbling in the water seal chamber indicates an air leak in the
system, such as from a loose connection or a leak at the insertion site. Fluctuation
(tidaling) in the water seal chamber (B) is a normal finding. Gentle bubbling in the
suction control chamber (C) is also normal and indicates suction is applied. Drainage (D)
is expected.
Question 6: A nurse is reviewing the arterial blood gas (ABG) results of a
client: pH 7.30, PaCO2 50 mm Hg, HCO3 24 mEq/L. Which of the following
conditions is consistent with these findings?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
CORRECT ANSWER: C. Respiratory acidosis
Rationale: The ABG shows a low pH (acidemia), elevated PaCO2 (hypercapnia), and
normal HCO3. This pattern is classic for respiratory acidosis, indicating hypoventilation
and carbon dioxide retention. Metabolic acidosis (A) would show a low HCO3.
Metabolic alkalosis (B) would show a high pH and high HCO3. Respiratory alkalosis (D)
would show a high pH and low PaCO2.
Question 7: A client is prescribed digoxin and furosemide for heart failure. The
nurse should monitor the client for which of the following potential electrolyte
imbalances that increases the risk of digoxin toxicity?
A. Hyperkalemia
B. Hypokalemia
C. Hypermagnesemia
D. Hypercalcemia
CORRECT ANSWER: B. Hypokalemia
Rationale: Furosemide is a loop diuretic that can cause potassium loss in the urine.
Hypokalemia increases the risk of digoxin toxicity because digoxin competes with
potassium at the Na-K-ATPase pump. Low serum potassium potentiates the effects of
digoxin, leading to cardiac dysrhythmias. Hyperkalemia (A) can decrease the effect of
digoxin.
, Question 8: A nurse is teaching a client about insulin administration. Which of
the following instructions is correct regarding the storage of unopened insulin
vials?
A. Store unopened vials in the refrigerator.
B. Store unopened vials at room temperature.
C. Store unopened vials in the freezer.
D. Store unopened vials in a dark cabinet to prevent degradation.
CORRECT ANSWER: A. Store unopened vials in the refrigerator.
Rationale: Unopened insulin vials should be stored in the refrigerator to maintain
potency until their expiration date. Once opened or in use, insulin can be stored at room
temperature for up to 28 days. Freezing (C) destroys insulin. While light protection is
recommended, refrigeration is the standard for unopened vials.
Question 9: A client is admitted with a diagnosis of acute pancreatitis. Which
of the following laboratory results is most specific for this condition?
A. Elevated serum lipase
B. Elevated serum glucose
C. Decreased serum calcium
D. Elevated serum bilirubin
CORRECT ANSWER: A. Elevated serum lipase
Rationale: Serum lipase is the most specific laboratory test for acute pancreatitis
because it is produced only by the pancreas. It rises within 4-8 hours of onset and
remains elevated longer than serum amylase. While serum glucose (B) may be elevated,
it is not specific. Decreased calcium (C) can occur but is a complication, and elevated
bilirubin (D) may suggest biliary obstruction.
Question 10: A nurse is caring for a client with a nasogastric (NG) tube
attached to continuous suction. Which of the following assessments indicates
that the NG tube is properly placed?
A. The client reports no abdominal pain
B. Aspirate pH is 3
C. The tube is taped securely to the nose
D. Bowel sounds are hyperactive
CORRECT ANSWER: B. Aspirate pH is 3
Rationale: A low pH (less than 5) of gastric aspirate indicates that the tube is likely in
the stomach. This is a reliable method for checking placement. While proper taping (C)
and absence of pain (A) are important, they do not confirm placement. Hyperactive
bowel sounds (D) are not a reliable indicator of NG tube placement.
Nursing Capstone Study Guide, Original Practice
Questions & Answers, Comprehensive NCLEX-RN®
Exam Preparation, NGN-Style Clinical Judgment,
Adult Medical-Surgical Nursing, Fundamentals,
Pharmacology, Maternal-Newborn, Pediatrics,
Mental Health, Leadership, Community Health,
Critical Care, Prioritization, Delegation, Patient
Safety, Health Assessment & Clinical Decision-
Making
Question 1: A nurse is caring for a client with a new diagnosis of syndrome of
inappropriate antidiuretic hormone (SIADH). Which of the following
laboratory findings would the nurse expect to be associated with this
condition?
A. Serum sodium 155 mEq/L and serum osmolality 310 mOsm/kg
B. Serum sodium 120 mEq/L and serum osmolality 260 mOsm/kg
C. Serum potassium 5.5 mEq/L and serum osmolality 290 mOsm/kg
D. Serum calcium 11.5 mg/dL and serum osmolality 300 mOsm/kg
CORRECT ANSWER: B. Serum sodium 120 mEq/L and serum osmolality 260
mOsm/kg
Rationale: SIADH is characterized by excessive release of antidiuretic hormone (ADH),
leading to water retention, dilutional hyponatremia, and decreased serum osmolality. A
serum sodium of 120 mEq/L (low) and an osmolality of 260 mOsm/kg (low) are
hallmark findings. Option A reflects hypernatremia and high osmolality, which are seen
in diabetes insipidus. Options C and D are incorrect as they reflect hyperkalemia and
hypercalcemia, respectively, which are not primary features of SIADH.
Question 2: A nurse is preparing to administer a blood transfusion to a client.
Which of the following actions is most important for the nurse to take to
prevent a transfusion reaction?
A. Premedicate the client with diphenhydramine
B. Verify the client's identity and blood compatibility with another licensed nurse
C. Infuse the blood over 4 hours to prevent fluid overload
D. Keep the blood refrigerated at the bedside until the start of the infusion
CORRECT ANSWER: B. Verify the client's identity and blood compatibility with
another licensed nurse
Rationale: The most critical action to prevent a hemolytic transfusion reaction is the
verification of the client's identity and blood product compatibility with another licensed
nurse. This includes checking the client's name, date of birth, blood type, Rh factor, and
,unit number against the blood bag and the medical record. While premedication (A)
may help with allergic reactions, it does not prevent ABO incompatibility. Infusion time
(C) and storage (D) are important but secondary to accurate identification.
Question 3: A client in the emergency department is exhibiting signs of
anaphylaxis after receiving intravenous penicillin. Which of the following is
the priority nursing action?
A. Administer epinephrine intramuscularly
B. Apply high-flow oxygen via a non-rebreather mask
C. Establish a second large-bore intravenous line
D. Administer intravenous diphenhydramine
CORRECT ANSWER: A. Administer epinephrine intramuscularly
Rationale: In anaphylaxis, the priority is to reverse severe vasodilation, bronchospasm,
and hypotension. Epinephrine is the first-line treatment and should be administered
intramuscularly in the anterolateral thigh. While oxygen (B), IV access (C), and
diphenhydramine (D) are important, they are secondary to the immediate
administration of epinephrine.
Question 4: A nurse is providing discharge teaching to a client with heart
failure. Which of the following client statements indicates an understanding of
dietary restrictions?
A. "I can use salt substitutes freely because they do not contain sodium."
B. "I should limit my daily fluid intake to about 2 liters."
C. "I can eat canned soups as they are low in fat."
D. "I should avoid foods high in potassium like bananas."
CORRECT ANSWER: B. "I should limit my daily fluid intake to about 2 liters."
Rationale: Clients with heart failure are typically placed on fluid restrictions (often 1.5
to 2 liters per day) and a low-sodium diet to reduce preload and cardiac workload. Salt
substitutes (A) are often high in potassium and may contain sodium, so they should be
avoided unless approved. Canned soups (C) are high in sodium. Potassium restriction
(D) is not a standard recommendation for heart failure unless hyperkalemia is present.
Question 5: A nurse is assessing a client who has a chest tube connected to a
closed-chest drainage system. Which of the following findings indicates a
possible air leak?
A. Continuous bubbling in the water seal chamber
B. Fluctuation of fluid in the water seal chamber with respirations
,C. Gentle bubbling in the suction control chamber
D. Serosanguineous drainage in the collection chamber
CORRECT ANSWER: A. Continuous bubbling in the water seal chamber
Rationale: Continuous bubbling in the water seal chamber indicates an air leak in the
system, such as from a loose connection or a leak at the insertion site. Fluctuation
(tidaling) in the water seal chamber (B) is a normal finding. Gentle bubbling in the
suction control chamber (C) is also normal and indicates suction is applied. Drainage (D)
is expected.
Question 6: A nurse is reviewing the arterial blood gas (ABG) results of a
client: pH 7.30, PaCO2 50 mm Hg, HCO3 24 mEq/L. Which of the following
conditions is consistent with these findings?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
CORRECT ANSWER: C. Respiratory acidosis
Rationale: The ABG shows a low pH (acidemia), elevated PaCO2 (hypercapnia), and
normal HCO3. This pattern is classic for respiratory acidosis, indicating hypoventilation
and carbon dioxide retention. Metabolic acidosis (A) would show a low HCO3.
Metabolic alkalosis (B) would show a high pH and high HCO3. Respiratory alkalosis (D)
would show a high pH and low PaCO2.
Question 7: A client is prescribed digoxin and furosemide for heart failure. The
nurse should monitor the client for which of the following potential electrolyte
imbalances that increases the risk of digoxin toxicity?
A. Hyperkalemia
B. Hypokalemia
C. Hypermagnesemia
D. Hypercalcemia
CORRECT ANSWER: B. Hypokalemia
Rationale: Furosemide is a loop diuretic that can cause potassium loss in the urine.
Hypokalemia increases the risk of digoxin toxicity because digoxin competes with
potassium at the Na-K-ATPase pump. Low serum potassium potentiates the effects of
digoxin, leading to cardiac dysrhythmias. Hyperkalemia (A) can decrease the effect of
digoxin.
, Question 8: A nurse is teaching a client about insulin administration. Which of
the following instructions is correct regarding the storage of unopened insulin
vials?
A. Store unopened vials in the refrigerator.
B. Store unopened vials at room temperature.
C. Store unopened vials in the freezer.
D. Store unopened vials in a dark cabinet to prevent degradation.
CORRECT ANSWER: A. Store unopened vials in the refrigerator.
Rationale: Unopened insulin vials should be stored in the refrigerator to maintain
potency until their expiration date. Once opened or in use, insulin can be stored at room
temperature for up to 28 days. Freezing (C) destroys insulin. While light protection is
recommended, refrigeration is the standard for unopened vials.
Question 9: A client is admitted with a diagnosis of acute pancreatitis. Which
of the following laboratory results is most specific for this condition?
A. Elevated serum lipase
B. Elevated serum glucose
C. Decreased serum calcium
D. Elevated serum bilirubin
CORRECT ANSWER: A. Elevated serum lipase
Rationale: Serum lipase is the most specific laboratory test for acute pancreatitis
because it is produced only by the pancreas. It rises within 4-8 hours of onset and
remains elevated longer than serum amylase. While serum glucose (B) may be elevated,
it is not specific. Decreased calcium (C) can occur but is a complication, and elevated
bilirubin (D) may suggest biliary obstruction.
Question 10: A nurse is caring for a client with a nasogastric (NG) tube
attached to continuous suction. Which of the following assessments indicates
that the NG tube is properly placed?
A. The client reports no abdominal pain
B. Aspirate pH is 3
C. The tube is taped securely to the nose
D. Bowel sounds are hyperactive
CORRECT ANSWER: B. Aspirate pH is 3
Rationale: A low pH (less than 5) of gastric aspirate indicates that the tube is likely in
the stomach. This is a reliable method for checking placement. While proper taping (C)
and absence of pain (A) are important, they do not confirm placement. Hyperactive
bowel sounds (D) are not a reliable indicator of NG tube placement.
