Capstone Exam 1
2011 Health Act that provided health care benefits to uninsured individuals and families -
ANS-Affordable Care Act
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 - ANS-B- irrigate the NG tube
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 - ANS-C-
Administering the ordered metronidazole PO to the client
*LPNs can't assess, teach, or determine risk factors
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 - ANS-C-
Implementing contact precautions when providing care for the client
*can't teach, communicate with other departments about tests or monitor results
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 - ANS-C- blood being chagned by
epigastric secretions
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 - ANS-C- bowel patterns
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 - ANS-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 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 - ANS-A- administering
oxandrolone 5 mg daily
*LPNs can't assess, develop care plans or teach
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 -
ANS-C- encourage the client to obtain a complete physical exam since these symptoms are
sonsistent with an ulcer
A Nurse is caring for a clients on the med-surg unit. Which client is most at risk to develop a
nosocomial infection?
A- clinet with alcohol abuse admitted for detox
B- Client with Type I diabetes and peripheral neuropathy
C- Client recovering from a choleystectomy
D- Client with full thickness burns, an NG tube and a Foley - ANS-D- Full thickness burn, NG
tube and Foley
*Think immunosupression and avenues for infection
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
2011 Health Act that provided health care benefits to uninsured individuals and families -
ANS-Affordable Care Act
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 - ANS-B- irrigate the NG tube
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 - ANS-C-
Administering the ordered metronidazole PO to the client
*LPNs can't assess, teach, or determine risk factors
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 - ANS-C-
Implementing contact precautions when providing care for the client
*can't teach, communicate with other departments about tests or monitor results
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 - ANS-C- blood being chagned by
epigastric secretions
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 - ANS-C- bowel patterns
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 - ANS-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 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 - ANS-A- administering
oxandrolone 5 mg daily
*LPNs can't assess, develop care plans or teach
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 -
ANS-C- encourage the client to obtain a complete physical exam since these symptoms are
sonsistent with an ulcer
A Nurse is caring for a clients on the med-surg unit. Which client is most at risk to develop a
nosocomial infection?
A- clinet with alcohol abuse admitted for detox
B- Client with Type I diabetes and peripheral neuropathy
C- Client recovering from a choleystectomy
D- Client with full thickness burns, an NG tube and a Foley - ANS-D- Full thickness burn, NG
tube and Foley
*Think immunosupression and avenues for infection
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
