Capstone Exam 1 Questions and Answers revised

Capstone Exam 1 Questions and Answers revised A nurse is caring for clients in the ICU. Which client may be transferred to the step-down neuro unit? A- Client with head injury and seizure B- Client with an ischemic stroke 4 days ago with confusion C- Client who is 1-day post op after a transshpenoidal craniotomy with a cerebrospinal fluid leak D-Client with bacterial meningitis and a Glasgow coma sale of 7 B- client with an ischemic stroke 4 days ago with confusion. *Think what is normal and what is abnormal- who is most stable After a change of shift, you are assinged to care for the following clients, Which client should you assess first? A- 60 year old client on a ventilator for whom a sterile sputum specimen must be sent to the lab B- 55 year old with COPD and a pulse oximetry reading from the previous shift of 90% C- 70 year old with pneumonia who needs to be started on IV antibiotics D- 50 year old with asthma who complains of shortness of breath after using a bronchodilator D- 50 year old with asthma who complains of shortness of breath after using a brochodilator *Think ABCs, also not the desired effect of the brochodilator treatment; should be improved. The nurse just received report on the surgical ward. Which client should be assessed first? A- Peptic ulcer disease scheduled for a laparosopic choleycystectomy in 4 hours B- Multiple injuries after a motor vehicle crash C- Graves disease scheduled for a thyroidectomy D- Post-appendectomy waiting for discharge B- multiple injuries following a motor vehicle crash *think who is most unstable A hospital will receive a large number of clients because of a magor disaster in the city. Which client can be discharged first? A- 49 year old female 24 hours postop after hysterectomy B- 66 year old male 5 days post op after total hip replacement C- 79 year old female admitted 12 hours ago with pyrlonephritis D- 82 year old female admitted 5 days ago with a stage 3 pressure ulcer B- 66 year old male 5 days post op after total hip replacement *think who is most stable and would be safest to go home A nurse just received report on her client's at the first of the shift. Which client should be assessed first? A- 45 year old woman with a BP of 90/60 and hot, dry skin B- 37 year old man with BP 130/70, sleeping quietly in his bed C- 25 year old woman with fruity breath, excessive thrist and polyphagia D- 16 year old boy with irritability and tremor C- 25 year old woman with fruity breath, excessive thirst and polyphagia *who is showing definite signs of a problem not just questionable ones The staff nurse receives on her assignment for the shift. Which client should she assess first? A- A client reporting a headache with a pain score 3/10 B- A client with frequent watery diarrhea, abdominal pain, nausea C- A client with respirations of 20 and O2 sat of 94% on room ait D- A client with nausea after taking oral contrast for abdominal CT scan B- A client with frequent watery diarrhea, abdominal pain and nausea *think about dehyration and electrolyte inbalance The client with COPD tells the CNA that he did not get his annual flu shot this year and has not had a pneumonia vaccination. You would be sure to instruct the CNA to report which of these? A- Blood pressure of 152/84 mmHg B- Respiratory rate of 27 breaths per minute C- Heart rate of 92 beats/min D- Oral temperature of 38.4 D- Oral temperature of 38.4 *most indicitive of infection When assessing a 22-year old client who required emergency surgery and multiple transfusion 3 days ago, you find that the client looks anxious and has labred respirations at the rate of 38 breaths/min. The oxygen saturation is 90% with the oxygen delivery at 6 L/min via nasal cannula. Which action is most apropriate? A- Increase the flow rate on the oxygen to 10 L/min and reassess the client after about 10 minutes B- Assis the client in using the incentive spirometer and splint his chest with a pillow while he coughs C- Administer the ordered morpine sulfate to the client to decrease his anxiety and reduce the hyperventilation D- Switch the client to a nonrebreather mask at 95-100% oxygen and call the physician to discuss the client's status. D- Switch the client to a nonrebreather mask at 95-100% O2 and call the physician to discuss the client's status. *think Breathing/oxygen saturation (delievery)- make sure you don't choose anything that is bad practice like 10 L on a nasal cannula An office nurse just checked her secure email. Which message should the nurse return first? A- Multipara at 34 weeks with headache and blurred vision B- Primipara at 22 weeks with supine dizziness C- Primipara at 15 weeks says she has not felt baby move D- Multipara at 12 weeks with white vaginal discharge A- multipara at 34 weeks with headache and blurred vision *this is preeclampsia and that can be life threatening- think in order of severity The nurse is caring for clients in a rural hospital. Which client should be seen first? A- A young child with a sore throat after tonsillectomy B- A client 2 days postpartum with pain during breastfeeding C- A client with a long leg cast with pain after taking vicodin D- A client with pain 2 hours after a liver biopsy C- A client with a long leg cast with pain after taking vicodin *think compartment syndrome The staff nurse just received report for her shift. Which client will she need to assess first? A- A client with a left femur fracture in a cast B- A client complainin of a headache of 2/10 C- A client that had a laryngectomy 5 hours ago D- A client with a lung lobectomy 1 day ago C- A client with a laryngectomy 5 hours ago *concern for airway/laryngospasm As the triage nurse in the emergency department which client would be assessed first? A- 78 year old with an uncontrolled nosebleed B- 36 year old with nausea and comiting for 3 hours C- 6 year old with arm pain after falling off a chair D- 3 year old with a temp of 38.2 A- 78 year old with uncontrolled nosebleed *think most severe, ABCs bleeding=circulation and uncontrolled is bad A nurse is managing clients during an outbreak of Legionnaire's Disease. Which client is most at risk? A- 63 year old with end stage renal disease B- 79 year old with Alzheimer's C- 86 year old with right-sided cerebrovascular accident D- 82 year old with a fractured hip A- 63 year old with end stage renal disease *chronic condition that leads to immunospression- think immunospressed and avenues for infection In the care of clients with pain and discomfort, which task is most appropriate to delegate to the UAP? A- Assissting a client with preparation of a sitz bath B- Monitoring the client for signs of discomfort while ambulation C- Coaching the client to deep breathe during painful procedures D- Evaluating relief after applying a cold compress A- assisting the client with preparation of a sitz bath *UAPs can't assess, teach or evaluate The team is providing emergency care to a client who reveived an excessive dose of narcotic pain medication. Which task is best to delegate to the LPN/LVN? A- Calling the physician and reporting the siuation, using SBAR B- Giving the ordered dose of Narcan and evaluating the response to therapy C- Monitoring the respiratory status for the first 30 minutes D- Applying oxygen per nasal cannula as ordered D- Applying oxygen per the nasal cannula as ordered *LPNs can't evaulate or assess For care of a patient who has oral cancer, which task would be appropriate to delegate to an LPN/LVN? A- Assisting the patient to brush and floss B- Explaining when brushing and flossing are contraindicated C- Giving antacids and sucralfate suspension as ordered D- Recommending saliva substitutes C- Giving Antacids and sucralfate as ordered *LPNs can't teach You are working in an AIDs hospice facility that is also staffed with LPNs and UAPs. Which nursing action will you delegate to the LPN you are supervising? A- Assessing patients' nutritional needs and individualizing diet plans to improve nutrition B- Collecting data about the patients responses to medications used for pain and anorexia C- Teaching the UAPs about how to lower the risk for spreading infections D- Assisting patients with personal hygeine and other activities of daily liging as needed B- Collecting data about the patients responses to medications used for pain and anorexia *LPNs can't asses or teach. They can assist with personal hygeine and activities of daily living but so can a UAP A hospitilized patient with AIDS has a nursing diagnosis of Imbalanced Nutrition: Less than Body Requirements related to nausea and anorexia. Which nursing action is most appropriate to delegate to an LPN who is providing care to this patient? A- Administering oxandrolone 5 mg daily B- Assessing the patient for other nutritional risk factors C- Developing a plan of care to improve the patient's appetite D- Providing instructions about a high-calorie, high protein diet A- administering oxandrolone 5 mg daily *LPNs can't assess, develop care plans or teach The client's nursing diagnosis is deficient fluid volume realted to excessive fluid loss. Which action related to fluid mamagement should be delegated to a UAP? A- Administering IV fluids as prescribed by the physicians B- Providing straws and offering fluids between meals C- Developing a plan for added fluid intake over 24 hours D- Teaching family members to assist the client with fluid intake B- Providing straws and offering fluids between meals *UAPs can't administer IV fluids, develop care plans or teach The nursing care plan for a client with dehydration includes interventions for oral health. Which interventions are within the scope of practice for an LPN being supervised by a nurse? A- Reminding the client to avoid commercial mouthwashes B- Encouraging mouth rinsing with warm saline C- Observing the lips, tongue and mucous membranes D- Providing mouth care every 2 hours wile the client is awake E- Seeking a dietary consult to increase fluids on meal trays A, B, C, D *LPNs can't seek out consults The charge nurse assigned the care of a client with acute kidney failure and hypernatremia to you, a newly graduated RN. Which action can you delegate to the UAP? A- Providing oral care every 3-4 hours B- Monitoring for indications of dehydration C- Aministering 0.45% saline by IV line D- Assessing daily weights for trends A- providing oral care every 3-4 hours *UAPs can't monitor for signs or trends and can't do IVs Which action should you delegate to a UAP for the client with diabetic ketoacidosis? A- checking fingerstick glucose results every hour B- Recording intake and output every hour C- Measuring vital signs every 15 minutes D- Assessing for indicators of fluid imbalance E- Notifying the provider of changes in glucose level B, C *UAPs can obtain measurements but not analyze them or trend them in any way. You are caring for a client who has been admitted to the hospital with a leg ulcer that is fected with vancomycin-resistant S. aureus (VRSA). Which nursing action can you delegate to an LPN? A- Planning ways to improve the client's oral protein intake B- Teaching the client about home care of the leg ulcer C- Obtaining wound cultures during dressing changes D- Assessing the risk for further skin breakdown C- obtaining wound cultures during dressing changes *can't plans, teach or assess A client with a vancomycin-resistant enterococcus (VRE) is admitted to the medical unit. Which action can be delegated to the UAP who is assesting with the client's care? A- Teaching the client and family members about means to prevent transmission of VRE B- Communicating with other departments when the client is transported for ordered tests C- Implementing contact precaustions when prociding care for the client D- Monitoring the results of ordered laboratory culture and semsitivity tests C- Implementing contact precautions when providing care for the client *can't teach, communicate with other departments about tests or monitor results A client who has frequent watery stools and a possible clostridium difficile infection is hospitilized with dehydration. Which nursing action should the chage nurse delegate to an LPN? A- Performing ongoing assessments to dtermine the client's hydration status B- Explaining the purpose of ordered stool cultures to the client and family C- Administering the ordered metronidazole PO to the client D- Reviewing the client's medical history for any risk factors for diarrhea C- Administering the ordered metronidazole PO to the client *LPNs can't assess, teach, or determine risk factors You are assigned to provide nursing care for a client reveiving mechanical ventilation. WHich action should you delegate to an experienced CNA? A- Assessing the client's respiratory status every 4 hours B- Taking vital signs and pulse oximitry reading every 4 hours C- Checking the vent settings to make sure they are as prescribed D- Observing wheter the client's tube needs suctioning every two hours B- taking vital signs and pusle oximitry reading every 4 hours *only one with the CNA scope of practice Which intervention for a client with a PE could be delegated to the LPN on the care team? A- Evaluating the client's complaint of chest pain B- Monitoring laboratory values for changes in oxygenation C- Assessing for symptoms of respiratory failure D- Auscultating the lungs for crackles D- Auscultating the lungs for crackles An experienced LPN, under supervision of the team leader RN, is providing nursing care for a client with a respiratory problem. Which actions are appropriate to the scope of practice of an experienced LPN? A- auscultate breath sounds B- Administer medications bia metered dose inhaler C- Complete in depth admission assessment D- Initiate the nursing care plan E- Evaluate the cleint's technique for using MDIs A,B *can't assess, formulate care plans or evaluate Following discharge teaching a male client with duodenal ulcers tells the nurse that he will drink plenty of dairy products, such as mild, to help coat and protect his ulcer. What is the best follow-up action by the nurse? A- Review with the client the need to avoid foods that are rich in milk and cream B- Remind the client to take his prescibed sucralfate after meals to reduce pain C- Instruct the client to unsure mild products contain at least 4% milk fat D- Tell the client that water is the only liquid he can drink because of his ulcer A- review with the client the need to avoid foods that are rich in milk and cream A client with ulcerative colitis is receiving mesalamin 800 mg PO TID. Whic assessment is most important for the nurse to perform to assess the effectiveness of the medication? A- Respiratory Rate B- Blood pressure C- Bowel patterns D- White blood cell count C- bowel patterns The nurse is preparing to administer a histamine 2 receptor blocker antagonist to a client with peptic ulcer disease. The nurse understands that the primary purpose of this drug classification is to? A- Coat the stomach lining to prevent injury/inflammation when eating B- Decrease the amount of HCl secretion by the parietal cells in the stomach C- Increase the amount of HCO3 regulated by the kidneys D- Block bradykinin production by inflammatory regulators B- decrease the amount of Cl secretion by the parietal cells in the stomach A woman just learned that she was infected with H-pylori. Based on this finding, which health promotion practice should the nurse suggest? A- Instruct the client to start an exercise program B- Give the client H-pylori support group information C- Discuss palliative care otions with the client D- Encourage screening for a peptic ulcer D- encourage screening for a peptic ulcer The healthcare provider prescribes a low-fiber diet for a client with ulcerative colitis. Which food selection would indicate to the nurse the client understads the prescribed diet? A- Roasted turkey with canned vegetables B- Baked potatoes with skin and raw carrots C- pancakes with whole grain cereal D- Roast pork and fresh strawberries A- roasted turkey and canned vegetables The nurse is teaching a client about the antiulcer medication ranitidine which was newly prescribed. Which statement by the nurse best descibes the action of this drug? A- Neutralize gastric acid and decrease gastric pH B- Provide a protective coating over the gastric mucosa C- It effectively blocks 97% of the gastric acid secreted in the stomach D- It blocks the effects of histamine, causing decreased secretion of acid D- it blocks the effects of histamine, causing decrease secretion of acid Following breakfast, the nurse is preparing to administer 0900 medications to clinets on a medical floor. Which medication should be held until a later time? A- the pain medication, hydrocodone, for a 12 hour post op patient B- The mucosal barrier, sucralfate, for a client diagnosed with peptic ulcer disease C- The bronchodilator, albuterol, for a client complaining of an asthma attack D- The beta blocker, metroprolol, for a client with a blood pressure of 118/78 B- the mucosal barrier, sucralfate, for a clinet diagnosed with peptic ulcer disease A male client tells the nurse that he is concerned that he may have a stomach ulcer, because he is experiencing heartburn and a dull growing pain that is relieved when he eats. What is the best response by the nurse? A- Encourage the clent to go immediately to the ED for treatment B- Tell the client to alter his eating habits becaus ehe eats too much food, too fast C- Encourage the client to obtain a complete physical exam since these symptoms are consistent with an ulcer D- Tell the client that eating a large dinner closer to bedtime will help relieve the symptoms C- encourage the client to obtain a complete physical exam since these symptoms are sonsistent with an ulcer A client has an NG tube and complains of nausea. Which action by the nurse is most appropriate? A- Administer an antiemetic B- Irrigate the NG tube C- Notify the physician D- Reposition the tube B- irrigate the NG tube Which laboratory test reult will the nurse monitor when evaluatin the effects of therapy for a patient who has acute pancreatitis? A- Anion Gap B- Bilirubin C- Amylase D- Hemoglobin C- Amylase A young woman who has Crohn's disease devleops a fever and symptoms of a urinary tract infection with tan, fecal smelling urine. What information will the nurse add to a general teaching plan about UTIs in order to individualize the teaching for this patient? A- Bacteria in the urethra can enter tha perianal area B- Fistulas can form between the bowel and bladder C- Restrict fluids to maintain normal hydration D- Empty the bladder only before sexual intercourse B- Fistuals can form between the bowel and bladder Which nursing action will the nurse include in the plan of care for a 35 year old male patient admitted with an exacerbation of inflammaotry bowel disease? A- immediately request for total parenteral nutrition (TPN) B- Monitor stools for blood C- Ambulate two times daily D- Increase dietary fiber intake B- monitor stools for blood A patient with cirrhosis asks what the 'yellow bag' of IV fluid contains. What is the best response by the nurse? A- It contains thiamine and multivitamins to prevent confusion and ataxia B- It contains lorazepam (ativan) to control withdrawal delirium C- It provides all of your nutrition requirements D- It contains vitamin K and phenytoin to help control withdrawal symptoms A- it contains thiamine and multivitamins to prevent confusion and ataxia A client with peptic ulcer disease (PUD) reports dark, coffee ground vomitus. The nurse would recognize that this is a result from A- Mixing of blood and fecal contents B- Presence of mucous from the large intestine C- Blood being changed by gastric secretions D- Fresh bleeding in the epigastric stomach region C- blood being chagned by epigastric secretions Which assessment information will be the most important for the nurse to report to the health care provider about a patient with acute cholecycstitis? A- Urine is clear yellow B- stools are gray colored C- Decreased pain after analgesic D- Complaints of heartburn B- stools are gray colored LPNs Can... -administer meds -chart -take vitals -change dressings -collect specimens such as blood and urine -insert and care for urinary catheters -care for patients with vents and trachs -insert and care for NG tubes -provide feedings through nasogastric or G tubes -monitor patients -know when to call physicians -perform CPR -Execute a nursing care plan formulated by RN LPNs Cannot... -perform initial assessments -determine nursing diagnoses -patient teaching -evaluate care -push IV medications This literary character chose nursing because she had no other avenue for employment Sairy Gamp Founded the Henry Settlement Lillian Wald MASH showed the bility of nurses to cope with war by using what? Humor One Flew Over the Cuckoo's Nest increased awareness of the rights of which populations Vulnerable Lillian Wald is an early pioneer of what kind of nursing? Occupational Health What statue honors all military nurses? Spirit of Nursing This reinforces trust in nurse patient relationships Image of Nursing What war introduced specialists like CRNAs into the world of nursing? World War I What can serve as effective sources of rapid accurate information? Appropriate internet sites