NUR 2811 Nursing Capstone: Module
3 Exam with correct answers and
detailed rationales
Section 1: Prioritization and Delegation (Questions
1–20)
1. A nurse is caring for multiple clients on a medical-surgical unit. Which client
is at the highest risk for developing a nosocomial infection?
A. Client with alcohol use disorder admitted for detoxification
B. Client with Type 1 diabetes mellitus and peripheral neuropathy
C. Client recovering from a laparoscopic cholecystectomy
D. Client with full-thickness burns, NG tube, and Foley catheter
Rationale: Patients with extensive burns have a severely compromised skin barrier,
making them highly susceptible to infection. The presence of invasive devices such as
an NG tube and Foley catheter further increases infection risk by providing entry
points for microorganisms. Although diabetes and surgery also increase risk, the
combination of broken skin integrity and multiple invasive devices places the burn
patient at the greatest risk -1 .
2. Which client should the nurse prioritize for transfer from ICU to a step-down
neurological unit?
A. Client with acute head injury and seizures
B. Client with ischemic stroke 4 days ago and mild confusion
C. Client 1-day post-transsphenoidal craniotomy with CSF leak
D. Client with bacterial meningitis and Glasgow Coma Scale of 7
Rationale: The most stable client is the one with an ischemic stroke who is several
days post-event and only mildly confused. The other clients are unstable due to CSF
leak, decreased level of consciousness, or active neurological compromise -1 .
,3. After shift report, which client should the nurse assess first?
A. Ventilated client requiring sputum culture collection
B. COPD client with oxygen saturation of 90% from previous shift
C. Pneumonia client awaiting IV antibiotics
D. Asthma client reporting shortness of breath after bronchodilator use
Rationale: Shortness of breath after bronchodilator use suggests worsening
bronchospasm or treatment failure. This is an airway priority (ABCs). The other clients
are either stable or receiving routine care -1 .
4. Which postoperative client should the nurse assess first?
A. Client scheduled for laparoscopic cholecystectomy
B. Multiple trauma client from motor vehicle collision
C. Client scheduled for thyroidectomy
D. Client awaiting discharge after appendectomy
Rationale: Trauma patients are the most unstable and require immediate assessment
due to risk of internal injuries, hemorrhage, and airway compromise -1 .
5. During disaster triage, which client can be safely discharged first?
A. 24-hour post-hysterectomy client
B. 5-day post-total hip replacement client
C. 12-hour pyelonephritis admission
D. 5-day stage III pressure ulcer patient
Rationale: This client is the most stable and least dependent on acute care services
compared to infection or surgical complications -1 .
6. Which client requires immediate assessment after shift change?
A. BP 90/60 with hot, dry skin
B. Sleeping client with stable vital signs
,C. Fruity breath, polydipsia, and polyphagia
D. Irritable client with tremors
Rationale: These are classic signs of diabetic ketoacidosis (DKA), a life-threatening
metabolic emergency -1 .
7. Which finding should be immediately reported in a COPD patient without
pneumococcal vaccination?
A. BP 152/84 mmHg
B. Respiratory rate 27/min
C. Heart rate 92 bpm
D. Temperature 38.4°C
Rationale: Fever in a COPD patient indicates infection, which can trigger acute
respiratory deterioration. The other findings are either expected or less urgent -7 .
8. A postoperative patient has RR 38/min and oxygen saturation 90% on 6
L/min oxygen. What is the priority action?
A. Increase nasal cannula to 10 L/min
B. Encourage incentive spirometry
C. Administer morphine
D. Switch to non-rebreather mask and notify provider
Rationale: The patient is in acute respiratory distress and needs immediate high-
concentration oxygen, along with provider notification -7 .
9. Which obstetric message should the nurse prioritize?
A. Headache and blurred vision at 34 weeks
B. Supine dizziness at 22 weeks
C. No fetal movement at 15 weeks
D. Vaginal discharge at 12 weeks
, Rationale: These are signs of preeclampsia, a life-threatening pregnancy
complication -7 .
10. Which rural hospital client should be seen first?
A. Post-tonsillectomy child
B. Postpartum breastfeeding pain
C. Leg cast pain after analgesia
D. Liver biopsy pain 2 hours post-procedure
Rationale: Severe pain after immobilization may indicate compartment syndrome, a
surgical emergency -7 .
11. Which post-report client requires immediate attention?
A. Femur fracture in cast
B. Mild headache
C. 5-hour post-laryngectomy client
D. 1-day post-lobectomy client
Rationale: Airway obstruction risk is highest after laryngectomy; this is an ABC
priority -7 .
12. Which emergency department client is priority?
A. Nosebleed in elderly patient
B. Vomiting for 3 hours
C. Child with arm pain
D. Fever in toddler
Rationale: Uncontrolled bleeding poses immediate circulation risk -7 .
3 Exam with correct answers and
detailed rationales
Section 1: Prioritization and Delegation (Questions
1–20)
1. A nurse is caring for multiple clients on a medical-surgical unit. Which client
is at the highest risk for developing a nosocomial infection?
A. Client with alcohol use disorder admitted for detoxification
B. Client with Type 1 diabetes mellitus and peripheral neuropathy
C. Client recovering from a laparoscopic cholecystectomy
D. Client with full-thickness burns, NG tube, and Foley catheter
Rationale: Patients with extensive burns have a severely compromised skin barrier,
making them highly susceptible to infection. The presence of invasive devices such as
an NG tube and Foley catheter further increases infection risk by providing entry
points for microorganisms. Although diabetes and surgery also increase risk, the
combination of broken skin integrity and multiple invasive devices places the burn
patient at the greatest risk -1 .
2. Which client should the nurse prioritize for transfer from ICU to a step-down
neurological unit?
A. Client with acute head injury and seizures
B. Client with ischemic stroke 4 days ago and mild confusion
C. Client 1-day post-transsphenoidal craniotomy with CSF leak
D. Client with bacterial meningitis and Glasgow Coma Scale of 7
Rationale: The most stable client is the one with an ischemic stroke who is several
days post-event and only mildly confused. The other clients are unstable due to CSF
leak, decreased level of consciousness, or active neurological compromise -1 .
,3. After shift report, which client should the nurse assess first?
A. Ventilated client requiring sputum culture collection
B. COPD client with oxygen saturation of 90% from previous shift
C. Pneumonia client awaiting IV antibiotics
D. Asthma client reporting shortness of breath after bronchodilator use
Rationale: Shortness of breath after bronchodilator use suggests worsening
bronchospasm or treatment failure. This is an airway priority (ABCs). The other clients
are either stable or receiving routine care -1 .
4. Which postoperative client should the nurse assess first?
A. Client scheduled for laparoscopic cholecystectomy
B. Multiple trauma client from motor vehicle collision
C. Client scheduled for thyroidectomy
D. Client awaiting discharge after appendectomy
Rationale: Trauma patients are the most unstable and require immediate assessment
due to risk of internal injuries, hemorrhage, and airway compromise -1 .
5. During disaster triage, which client can be safely discharged first?
A. 24-hour post-hysterectomy client
B. 5-day post-total hip replacement client
C. 12-hour pyelonephritis admission
D. 5-day stage III pressure ulcer patient
Rationale: This client is the most stable and least dependent on acute care services
compared to infection or surgical complications -1 .
6. Which client requires immediate assessment after shift change?
A. BP 90/60 with hot, dry skin
B. Sleeping client with stable vital signs
,C. Fruity breath, polydipsia, and polyphagia
D. Irritable client with tremors
Rationale: These are classic signs of diabetic ketoacidosis (DKA), a life-threatening
metabolic emergency -1 .
7. Which finding should be immediately reported in a COPD patient without
pneumococcal vaccination?
A. BP 152/84 mmHg
B. Respiratory rate 27/min
C. Heart rate 92 bpm
D. Temperature 38.4°C
Rationale: Fever in a COPD patient indicates infection, which can trigger acute
respiratory deterioration. The other findings are either expected or less urgent -7 .
8. A postoperative patient has RR 38/min and oxygen saturation 90% on 6
L/min oxygen. What is the priority action?
A. Increase nasal cannula to 10 L/min
B. Encourage incentive spirometry
C. Administer morphine
D. Switch to non-rebreather mask and notify provider
Rationale: The patient is in acute respiratory distress and needs immediate high-
concentration oxygen, along with provider notification -7 .
9. Which obstetric message should the nurse prioritize?
A. Headache and blurred vision at 34 weeks
B. Supine dizziness at 22 weeks
C. No fetal movement at 15 weeks
D. Vaginal discharge at 12 weeks
, Rationale: These are signs of preeclampsia, a life-threatening pregnancy
complication -7 .
10. Which rural hospital client should be seen first?
A. Post-tonsillectomy child
B. Postpartum breastfeeding pain
C. Leg cast pain after analgesia
D. Liver biopsy pain 2 hours post-procedure
Rationale: Severe pain after immobilization may indicate compartment syndrome, a
surgical emergency -7 .
11. Which post-report client requires immediate attention?
A. Femur fracture in cast
B. Mild headache
C. 5-hour post-laryngectomy client
D. 1-day post-lobectomy client
Rationale: Airway obstruction risk is highest after laryngectomy; this is an ABC
priority -7 .
12. Which emergency department client is priority?
A. Nosebleed in elderly patient
B. Vomiting for 3 hours
C. Child with arm pain
D. Fever in toddler
Rationale: Uncontrolled bleeding poses immediate circulation risk -7 .
