NUR 2811 Capstone Module 1 Exam | International
College of Health Sciences
1. A registered nurse begins a shift with four assigned clients, and which client should receive the
nurse's assessment first based on immediate physiological priorities?
A. A client requesting assistance with breakfast
B. A client with new-onset shortness of breath and an oxygen saturation of 86%
C. A client awaiting routine discharge instructions
D. A client reporting chronic back discomfort rated 4 out of 10
Answer: B
Rationale: A is incorrect because breakfast assistance is not urgent. B is correct because acute hypoxemia
and respiratory distress threaten life and require immediate assessment. C can safely wait while an
unstable client is addressed. D represents a lower priority than an acute oxygenation problem.
1. When developing a nursing care plan for a newly admitted client, which activity should occur before
selecting specific nursing interventions for identified problems?
A. Collect and analyze comprehensive assessment information
B. Evaluate whether previously implemented interventions were successful
C. Document the client's response to treatment
D. Determine whether discharge teaching has been completed
Answer: A
Rationale: A is correct because assessment provides the information needed for clinical judgment and
planning. B and C occur during evaluation after interventions have been implemented. D may be important
later but does not precede initial assessment and care planning.
1. A nurse identifies several client needs during assessment, and which principle should guide the
nurse when determining which problem requires immediate attention?
A. Address the client who has been waiting the longest
B. Complete all documentation before providing interventions
C. Address threats to airway, breathing, circulation, and immediate safety first
D. Begin with the client whose treatment requires the least amount of time
Answer: C
1
,Rationale: A is incorrect because waiting time does not determine clinical priority. B delays necessary care.
C is correct because life-threatening physiological and safety problems take priority. D incorrectly prioritizes
convenience over client needs.
1. Which outcome statement is written most appropriately for a client who has impaired mobility and
requires assistance with ambulation during hospitalization?
A. The client will improve mobility sometime during hospitalization.
B. The nurse will encourage the client to walk more often.
C. The client should understand the importance of mobility before discharge.
D. The client will ambulate 50 feet with assistance twice during each shift.
Answer: D
Rationale: A is vague and lacks measurable criteria. B describes a nursing intervention rather than an
outcome. C is difficult to measure because “understand” is not specific. D is correct because it identifies a
measurable behavior, distance, assistance level, and frequency.
1. A client tells the nurse that prescribed treatment conflicts with personal beliefs, and which response
best demonstrates respect for the client's autonomy?
A. “Your healthcare provider knows what treatment is best for you.”
B. “Tell me more about your concerns so we can discuss safe options.”
C. “You should follow the treatment because refusing it could be dangerous.”
D. “Your family can decide whether you should continue treatment.”
Answer: B
Rationale: A and C are paternalistic and minimize autonomy. B is correct because it explores concerns while
supporting informed decision-making. D is inappropriate unless the client lacks decision-making capacity
and an authorized surrogate is required.
1. Which assignment is most appropriate for an unlicensed assistive personnel caring for a stable
hospitalized client with predictable needs?
A. Obtaining routine vital signs on a stable client
B. Performing the initial assessment of a newly admitted client
C. Developing a nursing diagnosis for a complex client
D. Evaluating whether a nursing intervention achieved its intended outcome
Answer: A
2
,Rationale: A is correct because routine vital signs on a stable client may be delegated when allowed by
policy and competency. B, C, and D require nursing assessment, clinical judgment, diagnosis, or evaluation
and should not be delegated to UAP.
1. A registered nurse delegates ambulation to an experienced nursing assistant, and which action
remains the RN's responsibility after delegation?
A. Asking the assistant whether the client wants to ambulate
B. Selecting the client's preferred walking shoes
C. Determining whether the delegated care was performed safely and effectively
D. Carrying the client's personal belongings during ambulation
Answer: C
Rationale: A, B, and D may be appropriate supportive activities but do not represent the RN's central
accountability. C is correct because the RN retains responsibility for supervision, evaluation, and overall
client outcomes after delegation.
1. A client suddenly becomes confused and restless while receiving oxygen therapy, and which
assessment should the nurse perform first?
A. Determine the client's preferred meal
B. Review the client's discharge medications
C. Ask the family about the client's employment history
D. Assess airway, breathing, oxygen saturation, and other immediate physiological findings
Answer: D
Rationale: A, B, and C are not immediate priorities. D is correct because sudden confusion can result from
hypoxemia or other acute physiological problems, requiring rapid assessment and intervention.
1. Which nursing intervention best demonstrates effective discharge education for a client who has
newly prescribed medication therapy?
A. Provide written instructions and ask the client to demonstrate understanding through teach-back
B. Tell the client to read the medication label after leaving the hospital
C. Ask a family member to explain the medication without involving the client
D. Give all information rapidly because discharge teaching should be brief
Answer: A
Rationale: A is correct because written information combined with teach-back verifies understanding. B is
insufficient. C unnecessarily excludes the client. D may result in incomplete learning and does not establish
comprehension.
1. A nurse realizes that an incorrect medication dose was administered, and what should the nurse do
first after recognizing the error?
3
, A. Complete an incident report before assessing the client
B. Assess the client immediately for actual or potential effects of the error
C. Wait until symptoms occur before notifying anyone
D. Ask another nurse to document the medication administration
Answer: B
Rationale: A is incorrect because client assessment takes priority over administrative reporting. B is correct
because immediate assessment identifies potential harm. C delays treatment. D does not address the
client's safety or the nurse's responsibility.
1. Which nursing action is most appropriate when a client refuses a treatment after receiving
understandable information about its benefits and risks?
A. Ask the family to persuade the client to accept treatment
B. Tell the client that refusal is not permitted
C. Respect the decision, assess understanding, and document the informed refusal
D. Administer the treatment because it was prescribed by the healthcare provider
Answer: C
Rationale: A may be inappropriate coercion. B violates autonomy. C is correct because competent clients
have the right to refuse treatment after informed discussion. D disregards the client's legal and ethical right
to self-determination.
1. Which observation provides the strongest evidence that a client understands newly taught insulin
self-administration instructions?
A. The client says, “I understand everything you explained.”
B. The family member says the teaching was clear.
C. The client signs the education form.
D. The client independently demonstrates the correct injection technique.
Answer: D
Rationale: A provides verbal reassurance but does not objectively demonstrate skill. B is indirect evidence.
C documents receipt of education rather than competence. D is correct because direct demonstration
verifies psychomotor learning.
1. A nurse is preparing a client for discharge after hospitalization, and which finding should cause the
nurse to delay discharge teaching and reassess the client?
A. New onset of severe dizziness and difficulty maintaining balance
B. The client asks for a copy of written instructions
C. The client reports mild hunger before leaving
D. The client requests information about follow-up appointments
4
College of Health Sciences
1. A registered nurse begins a shift with four assigned clients, and which client should receive the
nurse's assessment first based on immediate physiological priorities?
A. A client requesting assistance with breakfast
B. A client with new-onset shortness of breath and an oxygen saturation of 86%
C. A client awaiting routine discharge instructions
D. A client reporting chronic back discomfort rated 4 out of 10
Answer: B
Rationale: A is incorrect because breakfast assistance is not urgent. B is correct because acute hypoxemia
and respiratory distress threaten life and require immediate assessment. C can safely wait while an
unstable client is addressed. D represents a lower priority than an acute oxygenation problem.
1. When developing a nursing care plan for a newly admitted client, which activity should occur before
selecting specific nursing interventions for identified problems?
A. Collect and analyze comprehensive assessment information
B. Evaluate whether previously implemented interventions were successful
C. Document the client's response to treatment
D. Determine whether discharge teaching has been completed
Answer: A
Rationale: A is correct because assessment provides the information needed for clinical judgment and
planning. B and C occur during evaluation after interventions have been implemented. D may be important
later but does not precede initial assessment and care planning.
1. A nurse identifies several client needs during assessment, and which principle should guide the
nurse when determining which problem requires immediate attention?
A. Address the client who has been waiting the longest
B. Complete all documentation before providing interventions
C. Address threats to airway, breathing, circulation, and immediate safety first
D. Begin with the client whose treatment requires the least amount of time
Answer: C
1
,Rationale: A is incorrect because waiting time does not determine clinical priority. B delays necessary care.
C is correct because life-threatening physiological and safety problems take priority. D incorrectly prioritizes
convenience over client needs.
1. Which outcome statement is written most appropriately for a client who has impaired mobility and
requires assistance with ambulation during hospitalization?
A. The client will improve mobility sometime during hospitalization.
B. The nurse will encourage the client to walk more often.
C. The client should understand the importance of mobility before discharge.
D. The client will ambulate 50 feet with assistance twice during each shift.
Answer: D
Rationale: A is vague and lacks measurable criteria. B describes a nursing intervention rather than an
outcome. C is difficult to measure because “understand” is not specific. D is correct because it identifies a
measurable behavior, distance, assistance level, and frequency.
1. A client tells the nurse that prescribed treatment conflicts with personal beliefs, and which response
best demonstrates respect for the client's autonomy?
A. “Your healthcare provider knows what treatment is best for you.”
B. “Tell me more about your concerns so we can discuss safe options.”
C. “You should follow the treatment because refusing it could be dangerous.”
D. “Your family can decide whether you should continue treatment.”
Answer: B
Rationale: A and C are paternalistic and minimize autonomy. B is correct because it explores concerns while
supporting informed decision-making. D is inappropriate unless the client lacks decision-making capacity
and an authorized surrogate is required.
1. Which assignment is most appropriate for an unlicensed assistive personnel caring for a stable
hospitalized client with predictable needs?
A. Obtaining routine vital signs on a stable client
B. Performing the initial assessment of a newly admitted client
C. Developing a nursing diagnosis for a complex client
D. Evaluating whether a nursing intervention achieved its intended outcome
Answer: A
2
,Rationale: A is correct because routine vital signs on a stable client may be delegated when allowed by
policy and competency. B, C, and D require nursing assessment, clinical judgment, diagnosis, or evaluation
and should not be delegated to UAP.
1. A registered nurse delegates ambulation to an experienced nursing assistant, and which action
remains the RN's responsibility after delegation?
A. Asking the assistant whether the client wants to ambulate
B. Selecting the client's preferred walking shoes
C. Determining whether the delegated care was performed safely and effectively
D. Carrying the client's personal belongings during ambulation
Answer: C
Rationale: A, B, and D may be appropriate supportive activities but do not represent the RN's central
accountability. C is correct because the RN retains responsibility for supervision, evaluation, and overall
client outcomes after delegation.
1. A client suddenly becomes confused and restless while receiving oxygen therapy, and which
assessment should the nurse perform first?
A. Determine the client's preferred meal
B. Review the client's discharge medications
C. Ask the family about the client's employment history
D. Assess airway, breathing, oxygen saturation, and other immediate physiological findings
Answer: D
Rationale: A, B, and C are not immediate priorities. D is correct because sudden confusion can result from
hypoxemia or other acute physiological problems, requiring rapid assessment and intervention.
1. Which nursing intervention best demonstrates effective discharge education for a client who has
newly prescribed medication therapy?
A. Provide written instructions and ask the client to demonstrate understanding through teach-back
B. Tell the client to read the medication label after leaving the hospital
C. Ask a family member to explain the medication without involving the client
D. Give all information rapidly because discharge teaching should be brief
Answer: A
Rationale: A is correct because written information combined with teach-back verifies understanding. B is
insufficient. C unnecessarily excludes the client. D may result in incomplete learning and does not establish
comprehension.
1. A nurse realizes that an incorrect medication dose was administered, and what should the nurse do
first after recognizing the error?
3
, A. Complete an incident report before assessing the client
B. Assess the client immediately for actual or potential effects of the error
C. Wait until symptoms occur before notifying anyone
D. Ask another nurse to document the medication administration
Answer: B
Rationale: A is incorrect because client assessment takes priority over administrative reporting. B is correct
because immediate assessment identifies potential harm. C delays treatment. D does not address the
client's safety or the nurse's responsibility.
1. Which nursing action is most appropriate when a client refuses a treatment after receiving
understandable information about its benefits and risks?
A. Ask the family to persuade the client to accept treatment
B. Tell the client that refusal is not permitted
C. Respect the decision, assess understanding, and document the informed refusal
D. Administer the treatment because it was prescribed by the healthcare provider
Answer: C
Rationale: A may be inappropriate coercion. B violates autonomy. C is correct because competent clients
have the right to refuse treatment after informed discussion. D disregards the client's legal and ethical right
to self-determination.
1. Which observation provides the strongest evidence that a client understands newly taught insulin
self-administration instructions?
A. The client says, “I understand everything you explained.”
B. The family member says the teaching was clear.
C. The client signs the education form.
D. The client independently demonstrates the correct injection technique.
Answer: D
Rationale: A provides verbal reassurance but does not objectively demonstrate skill. B is indirect evidence.
C documents receipt of education rather than competence. D is correct because direct demonstration
verifies psychomotor learning.
1. A nurse is preparing a client for discharge after hospitalization, and which finding should cause the
nurse to delay discharge teaching and reassess the client?
A. New onset of severe dizziness and difficulty maintaining balance
B. The client asks for a copy of written instructions
C. The client reports mild hunger before leaving
D. The client requests information about follow-up appointments
4
