NUR 2811 CAPSTONE MODULE 2 ACTUAL EXAM 2026/2027 TEST BANK
PRACTICE QUESTIONS AND STUDY GUIDE COMPLETE ACCURATE EXAM
1. A nurse is caring for several adult clients during a busy clinical shift and
recognizes that one client who is receiving oxygen has developed increasing
restlessness, tachypnea, and a declining oxygen saturation despite the
prescribed oxygen therapy. Which action should the nurse take first?
A. Reassess the client, verify the oxygen delivery system, and immediately
address the deteriorating respiratory status
B. Document the findings and reassess the client again after completing the
remaining medication pass
C. Ask the nursing assistant to remain with the client while the nurse
completes routine assessments
D. Administer the client's scheduled oral medications before reassessing the
respiratory findings
Answer: A
2. A nurse is preparing a comprehensive discharge plan for an older adult who
has heart failure, diabetes mellitus, limited transportation, and difficulty
reading medication labels. Which intervention best demonstrates patient-
centered discharge planning?
A. Provide the same written discharge instructions routinely given to all
heart failure clients
B. Ask a family member to assume responsibility for all medications without
first assessing the client's preferences
C. Individualize the teaching by considering literacy, transportation,
medication-management abilities, preferences, and available support
D. Tell the client to contact the primary care provider if any problem occurs
after discharge
Answer: C
3. During medication administration, a nurse discovers that the medication
prepared for a client has a dosage different from the currently prescribed
order. The medication has not yet been administered. Which action is most
pg. 1
, appropriate?
A. Administer the medication because the difference is probably an
intentional adjustment
B. Hold the medication, verify the current order, and follow the facility's
medication-safety process for the discrepancy
C. Change the medication label independently and administer the revised
dose
D. Discard the medication and document that the prescription was
discontinued
Answer: B
4. A client with suspected sepsis becomes increasingly confused, develops
hypotension, and has a rapidly increasing respiratory rate. The nurse
recognizes that the client's condition may be deteriorating rapidly. Which
nursing priority is most appropriate?
A. Encourage oral fluids and reassess the client in one hour
B. Complete the routine head-to-toe assessment before notifying anyone
C. Place the client in a quiet environment to reduce stimulation
D. Initiate urgent assessment and escalation of care while supporting
airway, breathing, circulation, and prescribed sepsis interventions
Answer: D
5. A nurse is caring for a client with type 1 diabetes mellitus who is admitted
with nausea, vomiting, abdominal pain, hyperglycemia, and metabolic
acidosis. Which finding would most strongly support diabetic ketoacidosis?
A. Decreased serum ketones with metabolic alkalosis
B. Hyperglycemia accompanied by ketone production and metabolic
acidosis
C. Hypoglycemia accompanied by increased bicarbonate concentration
D. Normal blood glucose accompanied by respiratory alkalosis
Answer: B
6. A client receiving a continuous intravenous insulin infusion for diabetic
ketoacidosis has a rapidly falling serum glucose level while the metabolic
pg. 2
, acidosis has not yet resolved. Which nursing action is most appropriate?
A. Stop all insulin therapy immediately regardless of the laboratory findings
B. Administer a rapid-acting oral carbohydrate and discontinue intravenous
fluids
C. Continue monitoring glucose and metabolic parameters and anticipate
prescribed dextrose-containing therapy while insulin continues to address
ketosis
D. Replace insulin with a long-acting subcutaneous preparation immediately
Answer: C
7. A client with chronic heart failure reports a sudden three-pound weight
increase over two days, worsening bilateral ankle edema, and increasing
shortness of breath when lying flat. Which finding should the nurse
recognize as most concerning?
A. The rapid weight increase accompanied by worsening dyspnea and
edema
B. A request for assistance with selecting low-sodium foods
C. Mild fatigue occurring after a physical therapy session
D. Occasional thirst after eating a salty meal
Answer: A
8. A nurse is caring for a client receiving furosemide for fluid-volume excess
related to heart failure. Which laboratory result requires particular
attention because of the medication's potential electrolyte effect?
A. Serum sodium of 140 mEq/L
B. Serum potassium of 3.0 mEq/L
C. Serum chloride of 102 mEq/L
D. Serum calcium of 9.2 mg/dL
Answer: B
9. A client with acute pulmonary edema related to severe left-sided heart
failure is extremely dyspneic and has diffuse crackles. Which nursing
intervention should be implemented first?
A. Encourage the client to drink additional water
pg. 3
, B. Place the client flat and encourage rest
C. Position the client upright, support oxygenation, and rapidly implement
prescribed interventions
D. Delay oxygen therapy until a complete medication history is obtained
Answer: C
10. A nurse is caring for a client with chronic obstructive pulmonary disease
who has an oxygen prescription. The client becomes increasingly dyspneic
and anxious. Which approach is most appropriate?
A. Withhold oxygen because oxygen therapy is contraindicated in every
client with COPD
B. Provide oxygen exactly as prescribed while monitoring respiratory status
and oxygenation
C. Encourage the client to breathe rapidly to increase oxygen intake
D. Place the client supine to improve diaphragmatic movement
Answer: B
11. A client with COPD is experiencing dyspnea and is using accessory muscles
to breathe. Which nursing intervention can help improve ventilation while
reducing anxiety associated with breathlessness?
A. Encourage prolonged breath holding after each inspiration
B. Teach pursed-lip breathing and position the client to facilitate lung
expansion
C. Encourage rapid shallow breathing through the mouth
D. Restrict all communication until the respiratory rate decreases
Answer: B
12. A client with pneumonia has a temperature of 39.1°C, productive cough,
tachycardia, and increasing oxygen requirements. Which finding should
prompt the nurse to escalate care most urgently?
A. Productive cough with yellow sputum
B. Temperature of 39.1°C
C. Increasing oxygen requirement accompanied by worsening respiratory
distress
pg. 4
PRACTICE QUESTIONS AND STUDY GUIDE COMPLETE ACCURATE EXAM
1. A nurse is caring for several adult clients during a busy clinical shift and
recognizes that one client who is receiving oxygen has developed increasing
restlessness, tachypnea, and a declining oxygen saturation despite the
prescribed oxygen therapy. Which action should the nurse take first?
A. Reassess the client, verify the oxygen delivery system, and immediately
address the deteriorating respiratory status
B. Document the findings and reassess the client again after completing the
remaining medication pass
C. Ask the nursing assistant to remain with the client while the nurse
completes routine assessments
D. Administer the client's scheduled oral medications before reassessing the
respiratory findings
Answer: A
2. A nurse is preparing a comprehensive discharge plan for an older adult who
has heart failure, diabetes mellitus, limited transportation, and difficulty
reading medication labels. Which intervention best demonstrates patient-
centered discharge planning?
A. Provide the same written discharge instructions routinely given to all
heart failure clients
B. Ask a family member to assume responsibility for all medications without
first assessing the client's preferences
C. Individualize the teaching by considering literacy, transportation,
medication-management abilities, preferences, and available support
D. Tell the client to contact the primary care provider if any problem occurs
after discharge
Answer: C
3. During medication administration, a nurse discovers that the medication
prepared for a client has a dosage different from the currently prescribed
order. The medication has not yet been administered. Which action is most
pg. 1
, appropriate?
A. Administer the medication because the difference is probably an
intentional adjustment
B. Hold the medication, verify the current order, and follow the facility's
medication-safety process for the discrepancy
C. Change the medication label independently and administer the revised
dose
D. Discard the medication and document that the prescription was
discontinued
Answer: B
4. A client with suspected sepsis becomes increasingly confused, develops
hypotension, and has a rapidly increasing respiratory rate. The nurse
recognizes that the client's condition may be deteriorating rapidly. Which
nursing priority is most appropriate?
A. Encourage oral fluids and reassess the client in one hour
B. Complete the routine head-to-toe assessment before notifying anyone
C. Place the client in a quiet environment to reduce stimulation
D. Initiate urgent assessment and escalation of care while supporting
airway, breathing, circulation, and prescribed sepsis interventions
Answer: D
5. A nurse is caring for a client with type 1 diabetes mellitus who is admitted
with nausea, vomiting, abdominal pain, hyperglycemia, and metabolic
acidosis. Which finding would most strongly support diabetic ketoacidosis?
A. Decreased serum ketones with metabolic alkalosis
B. Hyperglycemia accompanied by ketone production and metabolic
acidosis
C. Hypoglycemia accompanied by increased bicarbonate concentration
D. Normal blood glucose accompanied by respiratory alkalosis
Answer: B
6. A client receiving a continuous intravenous insulin infusion for diabetic
ketoacidosis has a rapidly falling serum glucose level while the metabolic
pg. 2
, acidosis has not yet resolved. Which nursing action is most appropriate?
A. Stop all insulin therapy immediately regardless of the laboratory findings
B. Administer a rapid-acting oral carbohydrate and discontinue intravenous
fluids
C. Continue monitoring glucose and metabolic parameters and anticipate
prescribed dextrose-containing therapy while insulin continues to address
ketosis
D. Replace insulin with a long-acting subcutaneous preparation immediately
Answer: C
7. A client with chronic heart failure reports a sudden three-pound weight
increase over two days, worsening bilateral ankle edema, and increasing
shortness of breath when lying flat. Which finding should the nurse
recognize as most concerning?
A. The rapid weight increase accompanied by worsening dyspnea and
edema
B. A request for assistance with selecting low-sodium foods
C. Mild fatigue occurring after a physical therapy session
D. Occasional thirst after eating a salty meal
Answer: A
8. A nurse is caring for a client receiving furosemide for fluid-volume excess
related to heart failure. Which laboratory result requires particular
attention because of the medication's potential electrolyte effect?
A. Serum sodium of 140 mEq/L
B. Serum potassium of 3.0 mEq/L
C. Serum chloride of 102 mEq/L
D. Serum calcium of 9.2 mg/dL
Answer: B
9. A client with acute pulmonary edema related to severe left-sided heart
failure is extremely dyspneic and has diffuse crackles. Which nursing
intervention should be implemented first?
A. Encourage the client to drink additional water
pg. 3
, B. Place the client flat and encourage rest
C. Position the client upright, support oxygenation, and rapidly implement
prescribed interventions
D. Delay oxygen therapy until a complete medication history is obtained
Answer: C
10. A nurse is caring for a client with chronic obstructive pulmonary disease
who has an oxygen prescription. The client becomes increasingly dyspneic
and anxious. Which approach is most appropriate?
A. Withhold oxygen because oxygen therapy is contraindicated in every
client with COPD
B. Provide oxygen exactly as prescribed while monitoring respiratory status
and oxygenation
C. Encourage the client to breathe rapidly to increase oxygen intake
D. Place the client supine to improve diaphragmatic movement
Answer: B
11. A client with COPD is experiencing dyspnea and is using accessory muscles
to breathe. Which nursing intervention can help improve ventilation while
reducing anxiety associated with breathlessness?
A. Encourage prolonged breath holding after each inspiration
B. Teach pursed-lip breathing and position the client to facilitate lung
expansion
C. Encourage rapid shallow breathing through the mouth
D. Restrict all communication until the respiratory rate decreases
Answer: B
12. A client with pneumonia has a temperature of 39.1°C, productive cough,
tachycardia, and increasing oxygen requirements. Which finding should
prompt the nurse to escalate care most urgently?
A. Productive cough with yellow sputum
B. Temperature of 39.1°C
C. Increasing oxygen requirement accompanied by worsening respiratory
distress
pg. 4
