NUR 2811 CAPSTONE MODULE 2 ACTUAL EXAM 2026/2027 TEST BANK
PRACTICE QUESTIONS AND STUDY GUIDE COMPLETE ACCURATE EXAM
1. A nurse performs a comprehensive assessment of an adult client admitted
with several chronic health conditions. During the interview, the client
reports, “I have been feeling dizzy every time I stand up, and the room
seems to spin for several seconds.” Which finding should the nurse classify
as subjective data because it is information that cannot be directly
measured or observed by the nurse?
A. The client reports experiencing dizziness when standing.
B. The client's blood pressure decreases from 128/76 mm Hg while supine
to 98/60 mm Hg while standing.
C. The client demonstrates an unsteady gait when walking to the bathroom.
D. The nurse observes horizontal nystagmus during the neurologic
examination.
Answer: A
2. A nurse is completing an admission assessment for an older adult who has
been transferred from another facility. The client provides a detailed history
of previous surgeries, chronic illnesses, medications, allergies,
immunizations, and current symptoms, while the nurse also performs a
complete physical examination. Which type of nursing database is most
appropriate for this situation?
A. Emergency database
B. Complete database
C. Episodic database
D. Follow-up database
Answer: B
3. A nurse is caring for a client who has just arrived in the emergency
department with severe respiratory distress, cyanosis, and altered level of
consciousness. Because the client is unstable, the nurse must obtain
information rapidly while simultaneously initiating life-saving interventions.
1
, Which type of assessment database should guide the nurse's initial
information gathering?
A. Complete database
B. Follow-up database
C. Emergency database
D. Episodic database
Answer: C
4. A client with advanced cancer is considering whether to undergo a high-risk
surgical procedure that might prolong life but could also result in significant
complications. The healthcare team explains the benefits, risks, and
alternatives and then allows the competent client to make the final decision
without coercion. Which ethical principle is the nurse primarily supporting?
A. Justice
B. Fidelity
C. Nonmaleficence
D. Autonomy
Answer: D
5. A nurse is caring for four hospitalized clients and receives several requests
for assistance at the same time. One client reports new crushing substernal
chest pain, another requests help locating personal belongings, another
needs routine vital signs, and another asks when the next meal will arrive.
Which client should the nurse assess first based on priority principles?
A. The client reporting new crushing chest pain
B. The client requesting help locating belongings
C. The client waiting for routine vital signs
D. The client asking about the next meal
Answer: A
6. A client with heart failure suddenly becomes severely dyspneic, has an
oxygen saturation of 82%, produces pink frothy sputum, and has diffuse
crackles. The nurse recognizes that the client may be experiencing acute
2
, pulmonary edema and immediately begins interventions directed toward
improving oxygenation. Which position is most appropriate while additional
treatment is initiated?
A. Supine with the legs elevated
B. High-Fowler's position with the legs dependent
C. Prone with the head turned laterally
D. Trendelenburg position
Answer: B
7. A client with type 1 diabetes mellitus is admitted with nausea, vomiting,
abdominal pain, deep rapid respirations, and a blood glucose level of 480
mg/dL. Laboratory testing demonstrates metabolic acidosis and elevated
serum ketones. Which complication should the nurse recognize as the most
likely explanation for these findings?
A. Hyperosmolar hyperglycemic state
B. Severe hypoglycemia
C. Diabetic ketoacidosis
D. Syndrome of inappropriate antidiuretic hormone secretion
Answer: C
8. A hospitalized client receiving unfractionated heparin develops a significant
platelet decrease several days after therapy begins and subsequently
develops a new painful swelling in the lower extremity. The nurse suspects
an immune-mediated adverse reaction associated with heparin therapy.
Which action is the priority?
A. Administer an additional dose of heparin.
B. Encourage ambulation to improve circulation.
C. Apply a warm compress and reassess tomorrow.
D. Stop heparin and notify the healthcare provider immediately.
Answer: D
9. A nurse is caring for a client who has a stage 3 pressure injury over the
sacral area. The wound contains full-thickness skin loss with visible adipose
3
, tissue but no exposed bone, tendon, or muscle. Which nursing intervention
is most appropriate for preventing further tissue damage?
A. Reposition the client regularly and reduce pressure on the affected area.
B. Massage the reddened tissue surrounding the wound vigorously.
C. Place the client directly on the pressure injury during meals.
D. Keep the wound uncovered regardless of drainage.
Answer: A
10. A client with advanced illness tells the nurse, “I do not want aggressive
treatment anymore. I want my family to understand that comfort is more
important to me now.” The client is alert, has decision-making capacity, and
has discussed these preferences with the healthcare team. Which nursing
response best demonstrates respect for the client's expressed goals?
A. “Your family should make this decision for you.”
B. “You should continue every treatment because stopping treatment is
unethical.”
C. “I will make sure your goals and preferences are communicated to the
healthcare team.”
D. “You cannot refuse treatment once you have been admitted.”
Answer: C
11. A nurse prepares to administer insulin to a hospitalized client. The
medication administration record lists regular insulin, while the vial selected
by the nurse is labeled NPH insulin. The nurse notices the discrepancy
immediately before administration. What is the safest action?
A. Administer the NPH insulin because both medications treat diabetes.
B. Hold the medication and verify the order and medication label before
administration.
C. Mix the two insulins and administer them together.
D. Ask the client which insulin is normally taken at home and administer
that one.
Answer: B
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PRACTICE QUESTIONS AND STUDY GUIDE COMPLETE ACCURATE EXAM
1. A nurse performs a comprehensive assessment of an adult client admitted
with several chronic health conditions. During the interview, the client
reports, “I have been feeling dizzy every time I stand up, and the room
seems to spin for several seconds.” Which finding should the nurse classify
as subjective data because it is information that cannot be directly
measured or observed by the nurse?
A. The client reports experiencing dizziness when standing.
B. The client's blood pressure decreases from 128/76 mm Hg while supine
to 98/60 mm Hg while standing.
C. The client demonstrates an unsteady gait when walking to the bathroom.
D. The nurse observes horizontal nystagmus during the neurologic
examination.
Answer: A
2. A nurse is completing an admission assessment for an older adult who has
been transferred from another facility. The client provides a detailed history
of previous surgeries, chronic illnesses, medications, allergies,
immunizations, and current symptoms, while the nurse also performs a
complete physical examination. Which type of nursing database is most
appropriate for this situation?
A. Emergency database
B. Complete database
C. Episodic database
D. Follow-up database
Answer: B
3. A nurse is caring for a client who has just arrived in the emergency
department with severe respiratory distress, cyanosis, and altered level of
consciousness. Because the client is unstable, the nurse must obtain
information rapidly while simultaneously initiating life-saving interventions.
1
, Which type of assessment database should guide the nurse's initial
information gathering?
A. Complete database
B. Follow-up database
C. Emergency database
D. Episodic database
Answer: C
4. A client with advanced cancer is considering whether to undergo a high-risk
surgical procedure that might prolong life but could also result in significant
complications. The healthcare team explains the benefits, risks, and
alternatives and then allows the competent client to make the final decision
without coercion. Which ethical principle is the nurse primarily supporting?
A. Justice
B. Fidelity
C. Nonmaleficence
D. Autonomy
Answer: D
5. A nurse is caring for four hospitalized clients and receives several requests
for assistance at the same time. One client reports new crushing substernal
chest pain, another requests help locating personal belongings, another
needs routine vital signs, and another asks when the next meal will arrive.
Which client should the nurse assess first based on priority principles?
A. The client reporting new crushing chest pain
B. The client requesting help locating belongings
C. The client waiting for routine vital signs
D. The client asking about the next meal
Answer: A
6. A client with heart failure suddenly becomes severely dyspneic, has an
oxygen saturation of 82%, produces pink frothy sputum, and has diffuse
crackles. The nurse recognizes that the client may be experiencing acute
2
, pulmonary edema and immediately begins interventions directed toward
improving oxygenation. Which position is most appropriate while additional
treatment is initiated?
A. Supine with the legs elevated
B. High-Fowler's position with the legs dependent
C. Prone with the head turned laterally
D. Trendelenburg position
Answer: B
7. A client with type 1 diabetes mellitus is admitted with nausea, vomiting,
abdominal pain, deep rapid respirations, and a blood glucose level of 480
mg/dL. Laboratory testing demonstrates metabolic acidosis and elevated
serum ketones. Which complication should the nurse recognize as the most
likely explanation for these findings?
A. Hyperosmolar hyperglycemic state
B. Severe hypoglycemia
C. Diabetic ketoacidosis
D. Syndrome of inappropriate antidiuretic hormone secretion
Answer: C
8. A hospitalized client receiving unfractionated heparin develops a significant
platelet decrease several days after therapy begins and subsequently
develops a new painful swelling in the lower extremity. The nurse suspects
an immune-mediated adverse reaction associated with heparin therapy.
Which action is the priority?
A. Administer an additional dose of heparin.
B. Encourage ambulation to improve circulation.
C. Apply a warm compress and reassess tomorrow.
D. Stop heparin and notify the healthcare provider immediately.
Answer: D
9. A nurse is caring for a client who has a stage 3 pressure injury over the
sacral area. The wound contains full-thickness skin loss with visible adipose
3
, tissue but no exposed bone, tendon, or muscle. Which nursing intervention
is most appropriate for preventing further tissue damage?
A. Reposition the client regularly and reduce pressure on the affected area.
B. Massage the reddened tissue surrounding the wound vigorously.
C. Place the client directly on the pressure injury during meals.
D. Keep the wound uncovered regardless of drainage.
Answer: A
10. A client with advanced illness tells the nurse, “I do not want aggressive
treatment anymore. I want my family to understand that comfort is more
important to me now.” The client is alert, has decision-making capacity, and
has discussed these preferences with the healthcare team. Which nursing
response best demonstrates respect for the client's expressed goals?
A. “Your family should make this decision for you.”
B. “You should continue every treatment because stopping treatment is
unethical.”
C. “I will make sure your goals and preferences are communicated to the
healthcare team.”
D. “You cannot refuse treatment once you have been admitted.”
Answer: C
11. A nurse prepares to administer insulin to a hospitalized client. The
medication administration record lists regular insulin, while the vial selected
by the nurse is labeled NPH insulin. The nurse notices the discrepancy
immediately before administration. What is the safest action?
A. Administer the NPH insulin because both medications treat diabetes.
B. Hold the medication and verify the order and medication label before
administration.
C. Mix the two insulins and administer them together.
D. Ask the client which insulin is normally taken at home and administer
that one.
Answer: B
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