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Exam (elaborations)

Capstone Exam 1 Questions with Detailed Verified Answers

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Capstone Exam 1 Questions with Detailed Verified Answers

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Capstone Exam 1 Questions with Detailed Verified
Answers



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

D-Client with bacterial meningitis and a Glasgow coma sale of 7 Ans: ✓ ✓ ✓ 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?
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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 Ans:
✓ ✓ ✓ 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 Ans: ✓ ✓ ✓ 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 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
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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 Ans: ✓ ✓ ✓ 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 Ans: ✓ ✓ ✓ 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 Ans: ✓ ✓ ✓ D- Oral temperature of 38.4

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