NUR210 Exam 3 V1 | Transition to Practice - Capstone Questions
With Answers and Explanations
Question 1. After education about Alcohol withdrawal, which statement indicates that further teaching is not
needed on this point?
A. 'I should not try to manage severe withdrawal alone if I have a history of seizures or delirium tremens.'
B. 'I will tell my clinician if voices become more commanding, frightening, or tell me to hurt myself or someone else.'
C. 'When my sleep decreases and I become unusually energetic or impulsive, I should contact my treatment team early.'
D. 'A situation can be a crisis for me even if another person might handle the same event differently.'
Correct Answer: A. 'I should not try to manage severe withdrawal alone if I have a history of seizures or delirium
tremens.'
Explanation: Prior severe withdrawal predicts increased risk and medically supervised detoxification may be necessary. The
statement reflects accurate self-management, prevention, medication use, or recognition of warning signs. The distractors
contain unsafe instructions or misconceptions that could delay treatment or increase complications. Effective discharge
teaching should be verified with teach-back and individualized to the client's prescribed plan.
Question 2. Which finding represents a major complication associated with Heparin and warfarin
anticoagulation?
A. Severe hypoglycemia with seizure or loss of consciousness
B. Major hemorrhage, including intracranial or gastrointestinal bleeding
C. Respiratory arrest, aspiration, or recurrent sedation after naloxone
D. Severe lithium neurotoxicity or hypertensive crisis from MAOI-tyramine interaction
Correct Answer: B. Major hemorrhage, including intracranial or gastrointestinal bleeding
Explanation: Excess anticoagulation or interacting drugs can convert therapeutic clot prevention into dangerous bleeding.
This complication has the strongest direct relationship to the pathophysiology or treatment risk described in the question. The
distractors are less characteristic, less urgent, or linked more closely to other conditions. Focused surveillance allows the
nurse to recognize deterioration early and initiate timely escalation.
Question 3. Which nursing intervention is most appropriate for a client with Hemorrhagic stroke?
A. Determine the exact last-known-well time and activate the stroke pathway for rapid imaging and reperfusion evaluation
B. Use a structured environment, simple communication, orientation cues, and safety measures tailored to functional ability
C. Monitor breathing and swallowing while supporting communication and advance care planning early
D. Support airway and perfusion, obtain urgent neuroimaging, and follow targeted blood-pressure and neurosurgical
management orders
Correct Answer: D. Support airway and perfusion, obtain urgent neuroimaging, and follow targeted
blood-pressure and neurosurgical management orders
Explanation: Hemorrhagic stroke requires rapid stabilization and bleeding-focused management rather than routine
thrombolysis. The chosen intervention best addresses the immediate physiologic or safety priority identified in the scenario.
The distractors would delay priority care, use an unsafe approach, or target a less urgent problem. After intervening, the nurse
should reassess the client's response and escalate care when expected improvement does not occur.
Page 1
,NUR210 Exam 3 V1 | Transition to Practice - Capstone
Question 4. Which clinical finding is most characteristic of Acute compartment syndrome?
A. Rapid rise in end-tidal carbon dioxide, muscle rigidity, tachycardia, acidosis, and later hyperthermia during or after
anesthesia
B. Severe pain out of proportion to the injury, pain with passive stretch, paresthesia, and a tense swollen compartment
C. Fragility fracture risk with loss of bone density, often without symptoms until a fracture occurs
D. Fat embolism syndrome
Correct Answer: B. Severe pain out of proportion to the injury, pain with passive stretch, paresthesia, and a tense
swollen compartment
Explanation: Rising pressure within a closed fascial compartment compromises capillary perfusion and nerve function. The
key is matching the characteristic assessment pattern or data set to the problem described in the stem. The distractors are
more consistent with other disorders or do not fit the defining assessment features presented. Early recognition helps the
nurse prioritize focused reassessment, notification, and treatment before deterioration occurs.
Question 5. Which room and respiratory protection are appropriate for a client requiring Airborne
Precautions?
A. A standard private room with the door open and a surgical mask only
B. A positive-pressure protective-environment room without a respirator
C. An airborne infection isolation room with a fit-tested N95 or higher-level respirator
D. A semiprivate room with a cloth face covering
Correct Answer: C. An airborne infection isolation room with a fit-tested N95 or higher-level respirator
Explanation: Airborne precautions require engineering controls and respiratory protection for pathogens that remain
suspended in air. This definition or principle directly matches the professional responsibility tested in the stem. The distractors
describe a different role, omit an essential safeguard, or conflict with safe nursing accountability. Applying the correct principle
supports consistent, patient-centered transition into entry-level RN practice.
Question 6. A nurse monitors a client with Hydrocephalus with ventriculoperitoneal shunt most closely for
which serious complication?
A. Wandering, falls, and caregiver strain as cognition and function decline
B. Persistent seizure activity with hypoxemia, hyperthermia, and metabolic complications
C. Shunt infection or obstruction causing acute increased intracranial pressure
D. Respiratory failure and aspiration from bulbar weakness
Correct Answer: C. Shunt infection or obstruction causing acute increased intracranial pressure
Explanation: Both infection and blockage can compromise CSF diversion and lead to neurologic decline. This complication
has the strongest direct relationship to the pathophysiology or treatment risk described in the question. The distractors are
less characteristic, less urgent, or linked more closely to other conditions. Focused surveillance allows the nurse to recognize
deterioration early and initiate timely escalation.
Page 2
,NUR210 Exam 3 V1 | Transition to Practice - Capstone
Question 7. A stable anxious client requests lengthy discharge teaching while another client has not voided
for 10 hours after surgery and has suprapubic fullness. Which need is higher priority?
A. Ask the postoperative client to wait until discharge planning is complete
B. Finish a routine satisfaction survey before addressing the distended bladder
C. Assess the postoperative client for urinary retention
D. Provide the anxious client's lengthy teaching before assessing urinary retention
Correct Answer: C. Assess the postoperative client for urinary retention
Explanation: Elimination is a basic physiologic need and the prolonged retention may cause injury, while teaching can briefly
wait. In this scenario, the selected response addresses the immediate professional responsibility while preserving appropriate
accountability. The distractors either delay needed action, transfer judgment to the wrong person, or use a less safe process.
The nurse should apply the principle consistently while following state law, facility policy, and the client's current condition.
Question 8. Which immediate nursing action best addresses the major risk associated with Heat stroke?
A. 8,400 mL
B. Use the designated disaster-triage system consistently and focus scarce resources on clients most likely to benefit from
rapid intervention
C. Obtain cultures promptly when ordered, give broad-spectrum antimicrobials and IV fluids without avoidable delay, trend
lactate, and use vasopressors if hypotension persists
D. Begin rapid active cooling, support airway and circulation, and monitor for electrolyte, renal, hepatic, and coagulation
complications
Correct Answer: D. Begin rapid active cooling, support airway and circulation, and monitor for electrolyte, renal,
hepatic, and coagulation complications
Explanation: Reducing core temperature quickly limits ongoing cellular and organ injury. The chosen intervention best
addresses the immediate physiologic or safety priority identified in the scenario. The distractors would delay priority care, use
an unsafe approach, or target a less urgent problem. After intervening, the nurse should reassess the client's response and
escalate care when expected improvement does not occur.
Question 9. Which immediate nursing action best addresses the major risk associated with
Electroconvulsive therapy?
A. Verify consent and preprocedure preparation, maintain NPO status as ordered, and monitor airway, vital signs, and
orientation after treatment
B. Assess privately when possible, document objective findings, treat urgent injuries, and follow mandatory reporting law
and facility policy
C. Assess immediate safety and supports, identify the precipitating problem, and focus on short-term achievable coping
strategies
D. Interview the client privately, assess immediate danger, validate concerns, document objectively, and offer safety
resources without forcing decisions
Correct Answer: A. Verify consent and preprocedure preparation, maintain NPO status as ordered, and monitor
airway, vital signs, and orientation after treatment
Explanation: Anesthesia and the induced seizure require standard procedural safety and postanesthesia monitoring. The
chosen intervention best addresses the immediate physiologic or safety priority identified in the scenario. The distractors
would delay priority care, use an unsafe approach, or target a less urgent problem. After intervening, the nurse should
reassess the client's response and escalate care when expected improvement does not occur.
Page 3
, NUR210 Exam 3 V1 | Transition to Practice - Capstone
Question 10. A nurse is assessing a client with Viral croup. Which finding is most consistent with this
condition?
A. Barking cough, hoarse voice, and inspiratory stridor that often worsens at night
B. Recurrent late decelerations associated with uteroplacental insufficiency
C. School-age children increasingly understand that death is final and may ask concrete questions about what happened
D. A healthy infant placed supine on a firm, flat sleep surface without loose bedding, pillows, or soft objects
Correct Answer: A. Barking cough, hoarse voice, and inspiratory stridor that often worsens at night
Explanation: Inflammation below the glottis narrows the pediatric airway and produces the characteristic barky cough and
stridor. The key is matching the characteristic assessment pattern or data set to the problem described in the stem. The
distractors are more consistent with other disorders or do not fit the defining assessment features presented. Early recognition
helps the nurse prioritize focused reassessment, notification, and treatment before deterioration occurs.
Question 11. Which step should generally occur before the nurse changes an intervention for a newly
reported symptom?
A. Implement a treatment before gathering relevant data
B. Document the symptom as expected without further evaluation
C. Focused assessment of the symptom and relevant data
D. Call the family before assessing the symptom
Correct Answer: C. Focused assessment of the symptom and relevant data
Explanation: Assessment supplies the information needed to identify the problem and choose a safe intervention. This
definition or principle directly matches the professional responsibility tested in the stem. The distractors describe a different
role, omit an essential safeguard, or conflict with safe nursing accountability. Applying the correct principle supports
consistent, patient-centered transition into entry-level RN practice.
Question 12. A nurse monitors a client with Obstructive sleep apnea most closely for which serious
complication?
A. Transmission to others or drug-resistant disease from incomplete therapy
B. Nocturnal hypoxemia and cardiovascular complications
C. Progressive bronchiectasis and respiratory failure
D. Iatrogenic pneumothorax after thoracentesis
Correct Answer: B. Nocturnal hypoxemia and cardiovascular complications
Explanation: Repeated apneas increase sympathetic activation and are associated with hypertension, dysrhythmias, and
other cardiovascular risks. This complication has the strongest direct relationship to the pathophysiology or treatment risk
described in the question. The distractors are less characteristic, less urgent, or linked more closely to other conditions.
Focused surveillance allows the nurse to recognize deterioration early and initiate timely escalation.
Page 4
With Answers and Explanations
Question 1. After education about Alcohol withdrawal, which statement indicates that further teaching is not
needed on this point?
A. 'I should not try to manage severe withdrawal alone if I have a history of seizures or delirium tremens.'
B. 'I will tell my clinician if voices become more commanding, frightening, or tell me to hurt myself or someone else.'
C. 'When my sleep decreases and I become unusually energetic or impulsive, I should contact my treatment team early.'
D. 'A situation can be a crisis for me even if another person might handle the same event differently.'
Correct Answer: A. 'I should not try to manage severe withdrawal alone if I have a history of seizures or delirium
tremens.'
Explanation: Prior severe withdrawal predicts increased risk and medically supervised detoxification may be necessary. The
statement reflects accurate self-management, prevention, medication use, or recognition of warning signs. The distractors
contain unsafe instructions or misconceptions that could delay treatment or increase complications. Effective discharge
teaching should be verified with teach-back and individualized to the client's prescribed plan.
Question 2. Which finding represents a major complication associated with Heparin and warfarin
anticoagulation?
A. Severe hypoglycemia with seizure or loss of consciousness
B. Major hemorrhage, including intracranial or gastrointestinal bleeding
C. Respiratory arrest, aspiration, or recurrent sedation after naloxone
D. Severe lithium neurotoxicity or hypertensive crisis from MAOI-tyramine interaction
Correct Answer: B. Major hemorrhage, including intracranial or gastrointestinal bleeding
Explanation: Excess anticoagulation or interacting drugs can convert therapeutic clot prevention into dangerous bleeding.
This complication has the strongest direct relationship to the pathophysiology or treatment risk described in the question. The
distractors are less characteristic, less urgent, or linked more closely to other conditions. Focused surveillance allows the
nurse to recognize deterioration early and initiate timely escalation.
Question 3. Which nursing intervention is most appropriate for a client with Hemorrhagic stroke?
A. Determine the exact last-known-well time and activate the stroke pathway for rapid imaging and reperfusion evaluation
B. Use a structured environment, simple communication, orientation cues, and safety measures tailored to functional ability
C. Monitor breathing and swallowing while supporting communication and advance care planning early
D. Support airway and perfusion, obtain urgent neuroimaging, and follow targeted blood-pressure and neurosurgical
management orders
Correct Answer: D. Support airway and perfusion, obtain urgent neuroimaging, and follow targeted
blood-pressure and neurosurgical management orders
Explanation: Hemorrhagic stroke requires rapid stabilization and bleeding-focused management rather than routine
thrombolysis. The chosen intervention best addresses the immediate physiologic or safety priority identified in the scenario.
The distractors would delay priority care, use an unsafe approach, or target a less urgent problem. After intervening, the nurse
should reassess the client's response and escalate care when expected improvement does not occur.
Page 1
,NUR210 Exam 3 V1 | Transition to Practice - Capstone
Question 4. Which clinical finding is most characteristic of Acute compartment syndrome?
A. Rapid rise in end-tidal carbon dioxide, muscle rigidity, tachycardia, acidosis, and later hyperthermia during or after
anesthesia
B. Severe pain out of proportion to the injury, pain with passive stretch, paresthesia, and a tense swollen compartment
C. Fragility fracture risk with loss of bone density, often without symptoms until a fracture occurs
D. Fat embolism syndrome
Correct Answer: B. Severe pain out of proportion to the injury, pain with passive stretch, paresthesia, and a tense
swollen compartment
Explanation: Rising pressure within a closed fascial compartment compromises capillary perfusion and nerve function. The
key is matching the characteristic assessment pattern or data set to the problem described in the stem. The distractors are
more consistent with other disorders or do not fit the defining assessment features presented. Early recognition helps the
nurse prioritize focused reassessment, notification, and treatment before deterioration occurs.
Question 5. Which room and respiratory protection are appropriate for a client requiring Airborne
Precautions?
A. A standard private room with the door open and a surgical mask only
B. A positive-pressure protective-environment room without a respirator
C. An airborne infection isolation room with a fit-tested N95 or higher-level respirator
D. A semiprivate room with a cloth face covering
Correct Answer: C. An airborne infection isolation room with a fit-tested N95 or higher-level respirator
Explanation: Airborne precautions require engineering controls and respiratory protection for pathogens that remain
suspended in air. This definition or principle directly matches the professional responsibility tested in the stem. The distractors
describe a different role, omit an essential safeguard, or conflict with safe nursing accountability. Applying the correct principle
supports consistent, patient-centered transition into entry-level RN practice.
Question 6. A nurse monitors a client with Hydrocephalus with ventriculoperitoneal shunt most closely for
which serious complication?
A. Wandering, falls, and caregiver strain as cognition and function decline
B. Persistent seizure activity with hypoxemia, hyperthermia, and metabolic complications
C. Shunt infection or obstruction causing acute increased intracranial pressure
D. Respiratory failure and aspiration from bulbar weakness
Correct Answer: C. Shunt infection or obstruction causing acute increased intracranial pressure
Explanation: Both infection and blockage can compromise CSF diversion and lead to neurologic decline. This complication
has the strongest direct relationship to the pathophysiology or treatment risk described in the question. The distractors are
less characteristic, less urgent, or linked more closely to other conditions. Focused surveillance allows the nurse to recognize
deterioration early and initiate timely escalation.
Page 2
,NUR210 Exam 3 V1 | Transition to Practice - Capstone
Question 7. A stable anxious client requests lengthy discharge teaching while another client has not voided
for 10 hours after surgery and has suprapubic fullness. Which need is higher priority?
A. Ask the postoperative client to wait until discharge planning is complete
B. Finish a routine satisfaction survey before addressing the distended bladder
C. Assess the postoperative client for urinary retention
D. Provide the anxious client's lengthy teaching before assessing urinary retention
Correct Answer: C. Assess the postoperative client for urinary retention
Explanation: Elimination is a basic physiologic need and the prolonged retention may cause injury, while teaching can briefly
wait. In this scenario, the selected response addresses the immediate professional responsibility while preserving appropriate
accountability. The distractors either delay needed action, transfer judgment to the wrong person, or use a less safe process.
The nurse should apply the principle consistently while following state law, facility policy, and the client's current condition.
Question 8. Which immediate nursing action best addresses the major risk associated with Heat stroke?
A. 8,400 mL
B. Use the designated disaster-triage system consistently and focus scarce resources on clients most likely to benefit from
rapid intervention
C. Obtain cultures promptly when ordered, give broad-spectrum antimicrobials and IV fluids without avoidable delay, trend
lactate, and use vasopressors if hypotension persists
D. Begin rapid active cooling, support airway and circulation, and monitor for electrolyte, renal, hepatic, and coagulation
complications
Correct Answer: D. Begin rapid active cooling, support airway and circulation, and monitor for electrolyte, renal,
hepatic, and coagulation complications
Explanation: Reducing core temperature quickly limits ongoing cellular and organ injury. The chosen intervention best
addresses the immediate physiologic or safety priority identified in the scenario. The distractors would delay priority care, use
an unsafe approach, or target a less urgent problem. After intervening, the nurse should reassess the client's response and
escalate care when expected improvement does not occur.
Question 9. Which immediate nursing action best addresses the major risk associated with
Electroconvulsive therapy?
A. Verify consent and preprocedure preparation, maintain NPO status as ordered, and monitor airway, vital signs, and
orientation after treatment
B. Assess privately when possible, document objective findings, treat urgent injuries, and follow mandatory reporting law
and facility policy
C. Assess immediate safety and supports, identify the precipitating problem, and focus on short-term achievable coping
strategies
D. Interview the client privately, assess immediate danger, validate concerns, document objectively, and offer safety
resources without forcing decisions
Correct Answer: A. Verify consent and preprocedure preparation, maintain NPO status as ordered, and monitor
airway, vital signs, and orientation after treatment
Explanation: Anesthesia and the induced seizure require standard procedural safety and postanesthesia monitoring. The
chosen intervention best addresses the immediate physiologic or safety priority identified in the scenario. The distractors
would delay priority care, use an unsafe approach, or target a less urgent problem. After intervening, the nurse should
reassess the client's response and escalate care when expected improvement does not occur.
Page 3
, NUR210 Exam 3 V1 | Transition to Practice - Capstone
Question 10. A nurse is assessing a client with Viral croup. Which finding is most consistent with this
condition?
A. Barking cough, hoarse voice, and inspiratory stridor that often worsens at night
B. Recurrent late decelerations associated with uteroplacental insufficiency
C. School-age children increasingly understand that death is final and may ask concrete questions about what happened
D. A healthy infant placed supine on a firm, flat sleep surface without loose bedding, pillows, or soft objects
Correct Answer: A. Barking cough, hoarse voice, and inspiratory stridor that often worsens at night
Explanation: Inflammation below the glottis narrows the pediatric airway and produces the characteristic barky cough and
stridor. The key is matching the characteristic assessment pattern or data set to the problem described in the stem. The
distractors are more consistent with other disorders or do not fit the defining assessment features presented. Early recognition
helps the nurse prioritize focused reassessment, notification, and treatment before deterioration occurs.
Question 11. Which step should generally occur before the nurse changes an intervention for a newly
reported symptom?
A. Implement a treatment before gathering relevant data
B. Document the symptom as expected without further evaluation
C. Focused assessment of the symptom and relevant data
D. Call the family before assessing the symptom
Correct Answer: C. Focused assessment of the symptom and relevant data
Explanation: Assessment supplies the information needed to identify the problem and choose a safe intervention. This
definition or principle directly matches the professional responsibility tested in the stem. The distractors describe a different
role, omit an essential safeguard, or conflict with safe nursing accountability. Applying the correct principle supports
consistent, patient-centered transition into entry-level RN practice.
Question 12. A nurse monitors a client with Obstructive sleep apnea most closely for which serious
complication?
A. Transmission to others or drug-resistant disease from incomplete therapy
B. Nocturnal hypoxemia and cardiovascular complications
C. Progressive bronchiectasis and respiratory failure
D. Iatrogenic pneumothorax after thoracentesis
Correct Answer: B. Nocturnal hypoxemia and cardiovascular complications
Explanation: Repeated apneas increase sympathetic activation and are associated with hypertension, dysrhythmias, and
other cardiovascular risks. This complication has the strongest direct relationship to the pathophysiology or treatment risk
described in the question. The distractors are less characteristic, less urgent, or linked more closely to other conditions.
Focused surveillance allows the nurse to recognize deterioration early and initiate timely escalation.
Page 4
