NURSING CAPSTONE COMPREHENSIVE PRE-TEST EXAM ACCURATE
REAL EXAM QUESTIONS AND VERIFIED ANSWERS WITH DETAILED
RATIONALES EACH | CURRENTLY TESTING AND FREQUENTLY TESTED
QUESTIONS |GRADED A+
SECTION 1: MANAGEMENT OF CARE (Questions 1-30)
QUESTION 1:
The nurse is assigned to care for four clients on a medical-surgical unit.
Which client should the nurse assess FIRST?
A. A client with COPD who has an SpO₂ of 89% on 2 L/min oxygen
B. A client with diabetes mellitus who has a blood glucose of 180 mg/dL
C. A client with heart failure who has 2+ pitting edema in the lower extremities
D. A client with pneumonia who has a temperature of 100.4°F (38°C)
ANSWER: A
RATIONALE: The client with COPD and SpO₂ of 89% is experiencing hypoxia and
requires immediate assessment and intervention. Oxygen saturation below 90%
indicates significant respiratory compromise that takes priority over the other
clients' conditions, which are stable or expected findings. The client with
diabetes has an elevated glucose but not in a critical range. The heart failure
client's edema is expected and manageable. The pneumonia client's fever is
concerning but not immediately life-threatening. According to Maslow's hierarchy
of needs, physiological needs (oxygenation) take priority.
QUESTION 2:
The charge nurse is making assignments for the next shift. Which client should
be assigned to an LPN/LVN?
A. A client 2 hours post-operative following a total hip replacement
B. A client with a new tracheostomy requiring frequent suctioning
C. A client receiving a continuous IV infusion of heparin
D. A client with stable heart failure requiring daily weights and medications
1
,ANSWER: D
RATIONALE: The LPN/LVN can care for stable clients with predictable outcomes.
The client with stable heart failure requiring daily weights and routine
medications falls within LPN scope of practice. The post-operative client, new
tracheostomy client, and client receiving continuous heparin require RN
assessment and complex nursing judgment. According to the National Council of
State Boards of Nursing (NCSBN), LPNs provide care for clients with stable and
predictable conditions.
QUESTION 3:
A nurse is preparing to delegate tasks to unlicensed assistive personnel (UAP).
Which task is appropriate to delegate?
A. Administering oral medications
B. Assessing a client's pain level
C. Measuring intake and output
D. Inserting a Foley catheter
ANSWER: C
RATIONALE: Measuring intake and output is a standard task that can be delegated
to UAP. Assessment, medication administration, and invasive procedures require
nursing judgment and cannot be delegated. The five rights of delegation include:
right task, right circumstance, right person, right direction/communication, and
right supervision/evaluation. UAP can perform tasks that are routine, have a
predictable outcome, and do not require complex assessment or clinical
judgment.
QUESTION 4:
The nurse is caring for a client who refuses a blood transfusion due to
religious beliefs. Which action should the nurse take?
A. Administer the transfusion anyway to save the client's life
2
,B. Notify the healthcare provider and document the client's refusal
C. Ask the family to persuade the client to accept the transfusion
D. Call the hospital ethics committee immediately
ANSWER: B
RATIONALE: The client has the right to refuse treatment under the principle of
autonomy. The nurse must respect the client's autonomy, notify the healthcare
provider, and document the refusal. The provider may explore alternative
treatments with the client. According to the American Nurses Association (ANA)
Code of Ethics, nurses must respect clients' rights to make decisions about
their care. Administering the transfusion against the client's wishes constitutes
battery. The ethics committee would be consulted for complex ethical dilemmas,
but this situation is straightforward regarding the client's right to refuse.
QUESTION 5:
A client is being discharged with a new colostomy. Which statement by the
client indicates a need for further teaching?
A. "I will change the pouch when it is one-third to one-half full"
B. "I can eat foods that I enjoy as long as I introduce them gradually"
C. "I will irrigate the colostomy daily to maintain regular bowel movements"
D. "I should avoid foods that cause gas and odor"
ANSWER: C
RATIONALE: Colostomy irrigation is not required for all clients and is generally
not recommended for ascending or transverse colostomies. Routine pouch
changes
and dietary management are appropriate. Clients should change the pouch when
one-third to one-half full to prevent leakage and skin breakdown. Foods should
be introduced gradually to identify tolerance. Foods that cause gas and odor
should be identified and avoided as needed. Colostomy irrigation is typically
used for descending or sigmoid colostomies to regulate bowel movements.
3
, QUESTION 6:
The nurse is admitting a client with a do-not-resuscitate (DNR) order. The
family requests that the nurse perform CPR if the client's heart stops. Which
response by the nurse is most appropriate?
A. "I will perform CPR if the family requests it"
B. "The DNR order must be honored; I cannot perform CPR"
C. "I will call the healthcare provider to discuss this with you"
D. "I will perform CPR only if the client is under 65 years old"
ANSWER: B
RATIONALE: A DNR order is a legal document that must be honored. The nurse
cannot perform CPR on a client with a valid DNR order. If the family disagrees,
the healthcare provider should be consulted to review the order. However, the
nurse must follow the existing order until it is legally changed. Performing CPR
on a client with a DNR order is a violation of the client's rights and can
result in legal consequences for the nurse.
QUESTION 7:
The nurse is preparing to discharge a client who speaks a different language.
Which action should the nurse take to ensure effective communication?
A. Use a family member as an interpreter
B. Use a certified medical interpreter
C. Speak loudly and slowly to the client
D. Use written instructions in English
ANSWER: B
RATIONALE: A certified medical interpreter should be used to ensure accurate
communication and maintain confidentiality. Family members may introduce
errors
or bias. Speaking loudly does not improve understanding. Written instructions
should be in the client's preferred language. Under Title VI of the Civil Rights
4
REAL EXAM QUESTIONS AND VERIFIED ANSWERS WITH DETAILED
RATIONALES EACH | CURRENTLY TESTING AND FREQUENTLY TESTED
QUESTIONS |GRADED A+
SECTION 1: MANAGEMENT OF CARE (Questions 1-30)
QUESTION 1:
The nurse is assigned to care for four clients on a medical-surgical unit.
Which client should the nurse assess FIRST?
A. A client with COPD who has an SpO₂ of 89% on 2 L/min oxygen
B. A client with diabetes mellitus who has a blood glucose of 180 mg/dL
C. A client with heart failure who has 2+ pitting edema in the lower extremities
D. A client with pneumonia who has a temperature of 100.4°F (38°C)
ANSWER: A
RATIONALE: The client with COPD and SpO₂ of 89% is experiencing hypoxia and
requires immediate assessment and intervention. Oxygen saturation below 90%
indicates significant respiratory compromise that takes priority over the other
clients' conditions, which are stable or expected findings. The client with
diabetes has an elevated glucose but not in a critical range. The heart failure
client's edema is expected and manageable. The pneumonia client's fever is
concerning but not immediately life-threatening. According to Maslow's hierarchy
of needs, physiological needs (oxygenation) take priority.
QUESTION 2:
The charge nurse is making assignments for the next shift. Which client should
be assigned to an LPN/LVN?
A. A client 2 hours post-operative following a total hip replacement
B. A client with a new tracheostomy requiring frequent suctioning
C. A client receiving a continuous IV infusion of heparin
D. A client with stable heart failure requiring daily weights and medications
1
,ANSWER: D
RATIONALE: The LPN/LVN can care for stable clients with predictable outcomes.
The client with stable heart failure requiring daily weights and routine
medications falls within LPN scope of practice. The post-operative client, new
tracheostomy client, and client receiving continuous heparin require RN
assessment and complex nursing judgment. According to the National Council of
State Boards of Nursing (NCSBN), LPNs provide care for clients with stable and
predictable conditions.
QUESTION 3:
A nurse is preparing to delegate tasks to unlicensed assistive personnel (UAP).
Which task is appropriate to delegate?
A. Administering oral medications
B. Assessing a client's pain level
C. Measuring intake and output
D. Inserting a Foley catheter
ANSWER: C
RATIONALE: Measuring intake and output is a standard task that can be delegated
to UAP. Assessment, medication administration, and invasive procedures require
nursing judgment and cannot be delegated. The five rights of delegation include:
right task, right circumstance, right person, right direction/communication, and
right supervision/evaluation. UAP can perform tasks that are routine, have a
predictable outcome, and do not require complex assessment or clinical
judgment.
QUESTION 4:
The nurse is caring for a client who refuses a blood transfusion due to
religious beliefs. Which action should the nurse take?
A. Administer the transfusion anyway to save the client's life
2
,B. Notify the healthcare provider and document the client's refusal
C. Ask the family to persuade the client to accept the transfusion
D. Call the hospital ethics committee immediately
ANSWER: B
RATIONALE: The client has the right to refuse treatment under the principle of
autonomy. The nurse must respect the client's autonomy, notify the healthcare
provider, and document the refusal. The provider may explore alternative
treatments with the client. According to the American Nurses Association (ANA)
Code of Ethics, nurses must respect clients' rights to make decisions about
their care. Administering the transfusion against the client's wishes constitutes
battery. The ethics committee would be consulted for complex ethical dilemmas,
but this situation is straightforward regarding the client's right to refuse.
QUESTION 5:
A client is being discharged with a new colostomy. Which statement by the
client indicates a need for further teaching?
A. "I will change the pouch when it is one-third to one-half full"
B. "I can eat foods that I enjoy as long as I introduce them gradually"
C. "I will irrigate the colostomy daily to maintain regular bowel movements"
D. "I should avoid foods that cause gas and odor"
ANSWER: C
RATIONALE: Colostomy irrigation is not required for all clients and is generally
not recommended for ascending or transverse colostomies. Routine pouch
changes
and dietary management are appropriate. Clients should change the pouch when
one-third to one-half full to prevent leakage and skin breakdown. Foods should
be introduced gradually to identify tolerance. Foods that cause gas and odor
should be identified and avoided as needed. Colostomy irrigation is typically
used for descending or sigmoid colostomies to regulate bowel movements.
3
, QUESTION 6:
The nurse is admitting a client with a do-not-resuscitate (DNR) order. The
family requests that the nurse perform CPR if the client's heart stops. Which
response by the nurse is most appropriate?
A. "I will perform CPR if the family requests it"
B. "The DNR order must be honored; I cannot perform CPR"
C. "I will call the healthcare provider to discuss this with you"
D. "I will perform CPR only if the client is under 65 years old"
ANSWER: B
RATIONALE: A DNR order is a legal document that must be honored. The nurse
cannot perform CPR on a client with a valid DNR order. If the family disagrees,
the healthcare provider should be consulted to review the order. However, the
nurse must follow the existing order until it is legally changed. Performing CPR
on a client with a DNR order is a violation of the client's rights and can
result in legal consequences for the nurse.
QUESTION 7:
The nurse is preparing to discharge a client who speaks a different language.
Which action should the nurse take to ensure effective communication?
A. Use a family member as an interpreter
B. Use a certified medical interpreter
C. Speak loudly and slowly to the client
D. Use written instructions in English
ANSWER: B
RATIONALE: A certified medical interpreter should be used to ensure accurate
communication and maintain confidentiality. Family members may introduce
errors
or bias. Speaking loudly does not improve understanding. Written instructions
should be in the client's preferred language. Under Title VI of the Civil Rights
4
