NUR 2811 Capstone Module 2 Exam |
Questions, Answers & Rationales |
International College of Health
Sciences | 2026/2027
1. A nurse is caring for a group of clients on a medical-surgical unit. Which of the
following clients should the nurse assess first?
• A. A client who is 1 day postoperative and reports pain at a level of 7 on a 0
to 10 scale.
• B. A client who has a new onset of confusion and a heart rate of 112/min.
• C. A client who is receiving a blood transfusion and reports chills and
lower back pain.
• D. A client who is scheduled for discharge and needs instructions on wound
care.
• Rationale: The client receiving a blood transfusion who reports chills
and lower back pain is exhibiting signs of a hemolytic transfusion reaction,
which is a life-threatening emergency. The nurse must stop the transfusion
immediately and assess this client first. Pain, new-onset confusion (which
could indicate hypoxia or infection), and discharge teaching are important
but are not immediately life-threatening priorities compared to a potential
transfusion reaction.
2. A charge nurse is assigning clients to a licensed practical nurse (LPN) and a
registered nurse (RN). Which of the following clients should be assigned to the
RN?
• A. A client who needs a dressing change for a stage 2 pressure injury.
• B. A client who requires a urinary catheter insertion.
• C. A client who is 4 hours postoperative following a craniotomy.
• D. A client who needs assistance with ambulation.
, • Rationale: The client who is 4 hours postoperative following a
craniotomy is unstable and requires the complex assessment and critical
thinking skills of an RN. The RN is responsible for assessing and monitoring
clients with complex, unstable conditions. LPNs can perform standard
dressing changes, catheter insertions, and assist with ambulation for stable
clients.
3. A nurse manager is reviewing the unit’s budget. Which of the following is an
example of a direct cost?
• A. The cost of electricity for the unit.
• B. The salary of the unit’s housekeeping staff.
• C. The salary of the registered nurses working on the unit.
• D. The cost of maintaining the hospital’s computer system.
• Rationale: Direct costs are expenses that are directly attributable to the
provision of care to clients. The salaries of nursing staff (RNs, LPNs, and
assistive personnel) are a primary example of a direct cost. Indirect costs,
such as electricity, housekeeping, and IT support, are necessary for the
facility to operate but are not directly tied to a specific client's care.
4. A nurse is using the SBAR communication tool to report a client’s condition to
a provider. Which of the following information should the nurse include in the
“A” section of SBAR?
• A. The client’s name and room number.
• B. The nurse’s suggestion for what should be done.
• C. The nurse’s assessment of the client’s current condition.
• D. A brief summary of the client’s background.
• Rationale: SBAR stands for Situation, Background, Assessment, and
Recommendation. The “A” stands for Assessment, where the nurse
provides their clinical impression of the client's current status (e.g., “I think
the client is developing sepsis”). The “S” is the situation (name, room,
, problem), the “B” is background (history, diagnosis), and the “R” is the
recommendation.
5. A nurse is delegating tasks to an assistive personnel (AP). Which of the
following tasks is appropriate for the nurse to delegate?
• A. Evaluating a client’s understanding of a new medication.
• B. Administering a tube feeding.
• C. Obtaining a client’s vital signs.
• D. Assessing a client’s incisional pain.
• Rationale: Obtaining vital signs on a stable client is a standard, routine
task that can be delegated to assistive personnel (AP). The nurse is
responsible for the assessment, evaluation, and teaching, which cannot be
delegated. Administering a tube feeding is a nursing intervention that may
be delegated to an LPN but not to an AP.
6. A nurse is prioritizing care for four clients. Which of the following clients
should the nurse see first?
• A. A client who is requesting pain medication for arthritis.
• B. A client who needs to be ambulated for the first time after surgery.
• C. A client who has new-onset shortness of breath and a respiratory
rate of 32/min.
• D. A client who is anxious about a scheduled procedure.
• Rationale: The nurse should see the client with new-onset shortness of
breath and a respiratory rate of 32/min first. This client is exhibiting signs of
respiratory distress, a life-threatening condition that requires immediate
assessment and intervention. The other clients have needs that are
important but not immediately life-threatening.
7. A nurse is preparing to administer medications to a group of clients. Which of
the following medications should the nurse administer first?
, • A. A routine antihypertensive medication for a client with a blood pressure
of 130/80 mm Hg.
• B. A PRN pain medication for a client who reports pain of 4 on a 0 to 10
scale.
• C. An antibiotic for a client who has a temperature of 38.9°C (102°F).
• D. A scheduled insulin dose for a client who is about to eat breakfast.
• Rationale: The nurse should administer the antibiotic first. A
temperature of 38.9°C (102°F) indicates a fever, and timely administration
of antibiotics for a suspected infection is a priority. The other medications
are important but can be administered after the antibiotic. The insulin
should be given with the meal, and the routine antihypertensive and PRN
pain medication are not immediate priorities.
8. A nurse manager is addressing a conflict between two staff nurses. Which of
the following is the most appropriate initial action by the nurse manager?
• A. Refer the conflict to the human resources department.
• B. Tell the nurses to resolve the conflict on their own.
• C. Meet with each nurse individually to gather information.
• D. Assign one of the nurses to a different shift.
• Rationale: The initial step in conflict resolution is to gather information
by meeting with each party involved individually. This allows the manager
to understand each nurse's perspective in a private, non-threatening
environment. Referring to HR or assigning a different shift are premature
and avoid addressing the core issue. Telling them to resolve it on their own
may be appropriate later but not as an initial action.
9. A nurse is caring for a client who has a DNR (do not resuscitate) order. The
client’s family member asks the nurse to “do everything” if the client’s heart
stops. Which of the following responses by the nurse is appropriate?
• A. “I will have to follow the doctor’s orders.”
• B. “We will do everything we can for your loved one.”
Questions, Answers & Rationales |
International College of Health
Sciences | 2026/2027
1. A nurse is caring for a group of clients on a medical-surgical unit. Which of the
following clients should the nurse assess first?
• A. A client who is 1 day postoperative and reports pain at a level of 7 on a 0
to 10 scale.
• B. A client who has a new onset of confusion and a heart rate of 112/min.
• C. A client who is receiving a blood transfusion and reports chills and
lower back pain.
• D. A client who is scheduled for discharge and needs instructions on wound
care.
• Rationale: The client receiving a blood transfusion who reports chills
and lower back pain is exhibiting signs of a hemolytic transfusion reaction,
which is a life-threatening emergency. The nurse must stop the transfusion
immediately and assess this client first. Pain, new-onset confusion (which
could indicate hypoxia or infection), and discharge teaching are important
but are not immediately life-threatening priorities compared to a potential
transfusion reaction.
2. A charge nurse is assigning clients to a licensed practical nurse (LPN) and a
registered nurse (RN). Which of the following clients should be assigned to the
RN?
• A. A client who needs a dressing change for a stage 2 pressure injury.
• B. A client who requires a urinary catheter insertion.
• C. A client who is 4 hours postoperative following a craniotomy.
• D. A client who needs assistance with ambulation.
, • Rationale: The client who is 4 hours postoperative following a
craniotomy is unstable and requires the complex assessment and critical
thinking skills of an RN. The RN is responsible for assessing and monitoring
clients with complex, unstable conditions. LPNs can perform standard
dressing changes, catheter insertions, and assist with ambulation for stable
clients.
3. A nurse manager is reviewing the unit’s budget. Which of the following is an
example of a direct cost?
• A. The cost of electricity for the unit.
• B. The salary of the unit’s housekeeping staff.
• C. The salary of the registered nurses working on the unit.
• D. The cost of maintaining the hospital’s computer system.
• Rationale: Direct costs are expenses that are directly attributable to the
provision of care to clients. The salaries of nursing staff (RNs, LPNs, and
assistive personnel) are a primary example of a direct cost. Indirect costs,
such as electricity, housekeeping, and IT support, are necessary for the
facility to operate but are not directly tied to a specific client's care.
4. A nurse is using the SBAR communication tool to report a client’s condition to
a provider. Which of the following information should the nurse include in the
“A” section of SBAR?
• A. The client’s name and room number.
• B. The nurse’s suggestion for what should be done.
• C. The nurse’s assessment of the client’s current condition.
• D. A brief summary of the client’s background.
• Rationale: SBAR stands for Situation, Background, Assessment, and
Recommendation. The “A” stands for Assessment, where the nurse
provides their clinical impression of the client's current status (e.g., “I think
the client is developing sepsis”). The “S” is the situation (name, room,
, problem), the “B” is background (history, diagnosis), and the “R” is the
recommendation.
5. A nurse is delegating tasks to an assistive personnel (AP). Which of the
following tasks is appropriate for the nurse to delegate?
• A. Evaluating a client’s understanding of a new medication.
• B. Administering a tube feeding.
• C. Obtaining a client’s vital signs.
• D. Assessing a client’s incisional pain.
• Rationale: Obtaining vital signs on a stable client is a standard, routine
task that can be delegated to assistive personnel (AP). The nurse is
responsible for the assessment, evaluation, and teaching, which cannot be
delegated. Administering a tube feeding is a nursing intervention that may
be delegated to an LPN but not to an AP.
6. A nurse is prioritizing care for four clients. Which of the following clients
should the nurse see first?
• A. A client who is requesting pain medication for arthritis.
• B. A client who needs to be ambulated for the first time after surgery.
• C. A client who has new-onset shortness of breath and a respiratory
rate of 32/min.
• D. A client who is anxious about a scheduled procedure.
• Rationale: The nurse should see the client with new-onset shortness of
breath and a respiratory rate of 32/min first. This client is exhibiting signs of
respiratory distress, a life-threatening condition that requires immediate
assessment and intervention. The other clients have needs that are
important but not immediately life-threatening.
7. A nurse is preparing to administer medications to a group of clients. Which of
the following medications should the nurse administer first?
, • A. A routine antihypertensive medication for a client with a blood pressure
of 130/80 mm Hg.
• B. A PRN pain medication for a client who reports pain of 4 on a 0 to 10
scale.
• C. An antibiotic for a client who has a temperature of 38.9°C (102°F).
• D. A scheduled insulin dose for a client who is about to eat breakfast.
• Rationale: The nurse should administer the antibiotic first. A
temperature of 38.9°C (102°F) indicates a fever, and timely administration
of antibiotics for a suspected infection is a priority. The other medications
are important but can be administered after the antibiotic. The insulin
should be given with the meal, and the routine antihypertensive and PRN
pain medication are not immediate priorities.
8. A nurse manager is addressing a conflict between two staff nurses. Which of
the following is the most appropriate initial action by the nurse manager?
• A. Refer the conflict to the human resources department.
• B. Tell the nurses to resolve the conflict on their own.
• C. Meet with each nurse individually to gather information.
• D. Assign one of the nurses to a different shift.
• Rationale: The initial step in conflict resolution is to gather information
by meeting with each party involved individually. This allows the manager
to understand each nurse's perspective in a private, non-threatening
environment. Referring to HR or assigning a different shift are premature
and avoid addressing the core issue. Telling them to resolve it on their own
may be appropriate later but not as an initial action.
9. A nurse is caring for a client who has a DNR (do not resuscitate) order. The
client’s family member asks the nurse to “do everything” if the client’s heart
stops. Which of the following responses by the nurse is appropriate?
• A. “I will have to follow the doctor’s orders.”
• B. “We will do everything we can for your loved one.”
