Medsurg Capstone Pre-assessment quiz
A nurse finds a client who has type 1 diabetes mellitus lying in bed, sweating, tachycardic, and
reporting feeling lightheaded and shaky. Which of the following complications should the nurse
expect? - ANS-Hypoglycemia
Rationale: the client who has hypoglycemia manifests sweating, tachycardia, tremors,
palpitations, hunger and lightheadedness
\A nurse is assessing an older adult client who has a urinary tract infection (UTI). Which of the
following findings should the nurse identify as unique for this age group? - ANS-Confusion
\A nurse is assisting with the care of a client who is 2 days postoperative following the creation
of a tracheostomy. Which of the following actins should the nurse plan to take? - ANS-Provide
humidified air
Rationale: the nurse should provide humidified air or oxygen as appropriate to the client's
condition. Humidification prevents drying of pulmonary secretions and will facilitate keeping the
client's airway clear
\A nurse is assisting with the care of a client who is receiving packed red blood cells. During the
infusion, the client states "My heart is racing". The nurse notes that the client's face has become
flushed. Which of the following actions should the nurse take? - ANS-Stop the transfusion
Rationale: The nurse should identify flushing and tachycardia as manifestations of an allergic
reaction to the blood transfusion. The first action the nurse should take is to stop the transfusion
immediately to prevent further reaction
\A nurse is caring for a child who is experiencing an acute asthma attack. Which of the following
medications should the nurse administer first? - ANS-Albuterol
Rationale: Albuterol is considered a rescue medication due to its rapid onset of action. Albuterol
is a beta2 adrenergic agonist used for the treatment of acute exacerbations of asthma. Albuterol
promotes broncho dilation and suppresses histamine release in the lungs
\A nurse is caring for a client who has a cholecystectomy and has a T-tube drain. Which of the
following actions should the nurse take? - ANS-Place the client into fowlers position
Rationale: the t-tube drains by gravity and placing the client in fowlers position with the
collection bag placed lower than the insertione site will aid in the drainage of bile
\A nurse is caring for a client who has cirrhosis and a prescription for lactulose. Following
administration, the nurse should monitor the client for which of the following adverse effects? -
ANS-Diarrhea
Rationale: The nurse should monitor for diarrhea. Lactulose is a synthetic disaccharide that the
small intestine cannot utilize. It causes diarrhea by lowering the pH, so the bacterial flora are
changed in the bowel
, \A nurse is caring for a client who has dysphagia following a stroke. Which of the following is the
priority action for the nurse to take when feeding the client? - ANS-Place the client in the upright
position
Rationale: the greatest risk to this client is injury from aspiration, therefore, the most important
action for the nurse to implement is to place the client in the upright position meals to facilitate
swallowing and prevent aspiration
\A nurse is caring for a client who has end-stage renal disease and must limit protein intake.
Which of the following foods should the nurse plan to include in the clients diet? - ANS-eggs
Rationale: the protein in the protein-restricted diet of a client who has end-stage renal disease
must be of high biological value. A high biological value means the protein source should be a
complete protein (providing a high percentage of amino acids) such as eggs, meat, fish, soy, or
dairy products
\A nurse is caring for a client who is postoperative and has an incision. To support tissue repair
the nurse should recommend that the client increase his dietary intake of which of the following?
- ANS-Complex carbohydrates
Rationale: The nurse should recommend that the client increase his dietary intake of complex
carbohydrates. Carbohydrates are protein-sparing food sources that provide energy and allow
the proteins to be used for tissue repair
\A nurse is caring for a client who is postoperative following a thyroidectomy. Which of the
following is a priority for the nurse to monitor during the first 24 hr of care for this client? -
ANS-Airway patency
Rationale: when using the airway, breathing, circulation approach to client care, the nurse
determines that the priority to monitor is airway patency. A thyroidectomy can result in edema or
bleeding that can obstruct the airway. provide humidification and elevate the client's head of bed
to reduce swelling
\A nurse is caring for a client who is suspected to have active laryngeal tuberculosis (TB). Which
of the following actions should the nurse plan to take to safely care for this client? - ANS-Place
the client in a private room with a special ventilation system
Rationale: Clients suspected to have active laryngeal tuberculosis are placed in private rooms
with negative-pressure airflow via HEPA filtration systems. Negative pressure pulls air away
from the hallway and exhausts it out of the room to areas away from the intake vents.
\A nurse is collecting data from a client who has an acute myocardial infarction (MI). Which of
the following clinical manifestations should the nurse expect to find? (select all that apply) -
ANS-Nausea, tachycardia, and diaphoresis
\A nurse is collecting data from a client who has left-sided heart failure. Which of the following
findings should the nurse expect? - ANS-Shortness of breath while laying down
\A nurse is collecting data from a client who has parkinsons disease and is experiencing
bradykinesia. Which of the following findings should the nurse expect? - ANS-Slurred speech
A nurse finds a client who has type 1 diabetes mellitus lying in bed, sweating, tachycardic, and
reporting feeling lightheaded and shaky. Which of the following complications should the nurse
expect? - ANS-Hypoglycemia
Rationale: the client who has hypoglycemia manifests sweating, tachycardia, tremors,
palpitations, hunger and lightheadedness
\A nurse is assessing an older adult client who has a urinary tract infection (UTI). Which of the
following findings should the nurse identify as unique for this age group? - ANS-Confusion
\A nurse is assisting with the care of a client who is 2 days postoperative following the creation
of a tracheostomy. Which of the following actins should the nurse plan to take? - ANS-Provide
humidified air
Rationale: the nurse should provide humidified air or oxygen as appropriate to the client's
condition. Humidification prevents drying of pulmonary secretions and will facilitate keeping the
client's airway clear
\A nurse is assisting with the care of a client who is receiving packed red blood cells. During the
infusion, the client states "My heart is racing". The nurse notes that the client's face has become
flushed. Which of the following actions should the nurse take? - ANS-Stop the transfusion
Rationale: The nurse should identify flushing and tachycardia as manifestations of an allergic
reaction to the blood transfusion. The first action the nurse should take is to stop the transfusion
immediately to prevent further reaction
\A nurse is caring for a child who is experiencing an acute asthma attack. Which of the following
medications should the nurse administer first? - ANS-Albuterol
Rationale: Albuterol is considered a rescue medication due to its rapid onset of action. Albuterol
is a beta2 adrenergic agonist used for the treatment of acute exacerbations of asthma. Albuterol
promotes broncho dilation and suppresses histamine release in the lungs
\A nurse is caring for a client who has a cholecystectomy and has a T-tube drain. Which of the
following actions should the nurse take? - ANS-Place the client into fowlers position
Rationale: the t-tube drains by gravity and placing the client in fowlers position with the
collection bag placed lower than the insertione site will aid in the drainage of bile
\A nurse is caring for a client who has cirrhosis and a prescription for lactulose. Following
administration, the nurse should monitor the client for which of the following adverse effects? -
ANS-Diarrhea
Rationale: The nurse should monitor for diarrhea. Lactulose is a synthetic disaccharide that the
small intestine cannot utilize. It causes diarrhea by lowering the pH, so the bacterial flora are
changed in the bowel
, \A nurse is caring for a client who has dysphagia following a stroke. Which of the following is the
priority action for the nurse to take when feeding the client? - ANS-Place the client in the upright
position
Rationale: the greatest risk to this client is injury from aspiration, therefore, the most important
action for the nurse to implement is to place the client in the upright position meals to facilitate
swallowing and prevent aspiration
\A nurse is caring for a client who has end-stage renal disease and must limit protein intake.
Which of the following foods should the nurse plan to include in the clients diet? - ANS-eggs
Rationale: the protein in the protein-restricted diet of a client who has end-stage renal disease
must be of high biological value. A high biological value means the protein source should be a
complete protein (providing a high percentage of amino acids) such as eggs, meat, fish, soy, or
dairy products
\A nurse is caring for a client who is postoperative and has an incision. To support tissue repair
the nurse should recommend that the client increase his dietary intake of which of the following?
- ANS-Complex carbohydrates
Rationale: The nurse should recommend that the client increase his dietary intake of complex
carbohydrates. Carbohydrates are protein-sparing food sources that provide energy and allow
the proteins to be used for tissue repair
\A nurse is caring for a client who is postoperative following a thyroidectomy. Which of the
following is a priority for the nurse to monitor during the first 24 hr of care for this client? -
ANS-Airway patency
Rationale: when using the airway, breathing, circulation approach to client care, the nurse
determines that the priority to monitor is airway patency. A thyroidectomy can result in edema or
bleeding that can obstruct the airway. provide humidification and elevate the client's head of bed
to reduce swelling
\A nurse is caring for a client who is suspected to have active laryngeal tuberculosis (TB). Which
of the following actions should the nurse plan to take to safely care for this client? - ANS-Place
the client in a private room with a special ventilation system
Rationale: Clients suspected to have active laryngeal tuberculosis are placed in private rooms
with negative-pressure airflow via HEPA filtration systems. Negative pressure pulls air away
from the hallway and exhausts it out of the room to areas away from the intake vents.
\A nurse is collecting data from a client who has an acute myocardial infarction (MI). Which of
the following clinical manifestations should the nurse expect to find? (select all that apply) -
ANS-Nausea, tachycardia, and diaphoresis
\A nurse is collecting data from a client who has left-sided heart failure. Which of the following
findings should the nurse expect? - ANS-Shortness of breath while laying down
\A nurse is collecting data from a client who has parkinsons disease and is experiencing
bradykinesia. Which of the following findings should the nurse expect? - ANS-Slurred speech
