Capstone Med Surg Assessment Exam 2023/24 latest Update Capstone 2023

Capstone Med Surg Assessment Exam 2023/24 latest Update Capstone 2023   1. A nurse is updating a plan of care after an evaluation of a client who has dysphagia. Which of the following interventions should the nurse include in the plan? a) Ask the client to tilt their head back when swallowing. b) Have the client sit upright for 1 hr. following meals. c) Administer liquids to the client using a syringe. d) Allow the client to rest for 10 min prior to eating. 2. A nurse is assessing the IV infusion site of a client who report pain at the site. The site is red and there is warmth along the course of the vein. Which of the following actions should the nurse take? a) Initiate a new IV line below the original insertion site. b) Discontinue the infusion c) Raise the head of the bed d) Obtain a culture from the area of the insertion site. 3. A nurse is preparing to perform a routine abdominal assessment for a client. Which of the following actions should the nurse take? a) Document shiny, taut skin as an expected finding. b) Perform palpitation after auscultation. c) Listen for 1 min before documenting absent bowel sounds d) Perform auscultation immediately after the client has consumed a meal. 4. A nurse is discussing immunity with a client who has received an immunization. The nurse should identify that an immunization functions as a part of the which of the following types of immunity? a) Passive immunity b) Active immunity c) Cellular immunity d) Acquired immunity 5. A nurse is reviewing the medical records of a group of older adult clients. The nurse should identify that which of the following is a risk factor that places olderclients at an increased risk for developing infections? a) Overproduction of lymphocytes b) Elevated albumin levels c) Lowered immune system function d) Increased body fat 6. A nurse is teaching a client who has asthma the use of a metered dose inhaler. Which of the following instructions should the nurse include in the teaching? a) Hold your breath for 6 seconds after inhaling the medication. b) Inhale the medication deeply for 5 seconds. c) Do not shake the medication in the inhaler d) Hold the inhaler 3 inches away from your mouth. 7. A nurse is performing a focused assessment on a client who has a history of COPD and is experiencing dyspnea. Which of the following findings should the nurse expect? a) Pulse oximetry reading of 95 % b) Decreased depth of respirations c) Flaring of the nostrils d) Respiratory rate of 16/min 8. A nurse is teaching a client about the correct use of a cane. Which of the following instruction should the nurse include in the teaching? (Selected all that apply) a) Ensure the cane has a rubber cap. b) Hold the cane on the weaker side. c) Flex the elbow slightly when using the cane. d) Move the cane and stronger leg forward simultaneously e) Use a quad cane for increased support. 9. A nurse is Use a quad cane for increased ing a group of assistive personnel about the expected integumentary changes in older adult clients. Which of the following findings should the nurse include in the teaching? a) Increase in subcutaneous tissue b) Decrease in pigmentation c) Increase in moisture levels d) Decrease in elasticity 17. A nurse s providing teaching about measures to promote sleep witha client who has insomnia. Which of the following client statements indicates an understanding of the teaching? a) “I can exercise as late as 2 hours before bedtime.” b) “I should reduce my fluid intake 2 hours before bedtime “ c) “I should take a 1 hours nap each day” d) “I can eat a large meal as late as 1 hours before bedtime” 18. A nurse is assessing the pain level of a client who has dementia and difficulty communicating. Which of the following pain assessment techniques should the nurse use? a) Numerical pain scale b) Verbal description c) Faces pain scale d) 19. A nurse in an emergency department is monitoring the hydration status of a client who is receiving oral rehydration. Which of the following findings should the nurse identify as requiring further interventions? a) b) BP 121/74 mm Hg c) Temperature 37.78 C (100 F) d) Urine specific gravity 1.020 20. A nurse in a provider’s office is assessing the motor skill development of a 15 month oldtoddler during a well child visit. Which of the following gross motor skills should the nurse expect? a) Takes several steps on tip toes b) Walks without assistance using a wide stance c) Has an accentuated cervical curvature when standing d) Stands with the feet turned slightly inward. 21. A nurse is teaching a group of parents and guardians about safety risks for adolescents. Which of the following statements should the nurse include in the teaching? a) “Exploring the environment commonly leads to injuries for this age group.” b) “Most injuries sustained during this time of life are caused by developing motor skills.”c) “At this age, peer influence to participate in high -risk behaviors can lead to injury” d) The risk for injuries sustained during this age are often a result of a changes in cognitive function” 22. A nurse is caring for a client who expresses anxiety about an upcoming surgery. Which of thefollowing actions should the nurse take? a) Ask the client to describe their feelings b) Discuss the competency of the surgeon with the client c) Inform the client that others have had the procedure without problems. d) Ask the client why they are experiencing anxiety. 23. A nurse is reviewing information about advance directives with a newly admitted client. Which of the following statements by the client indicates an understanding of the teaching? a) “I need to have an attorney sign my advance directives”b) c) “I “I have a living will that outlines my wishes if I am unable to make decisions”must have a family member appointed to make my health care decisions” d) “I will need to sign a document stating that I want to be resuscitated if I required CPR.” 24. A nurse is planning a community education program about colorectal cancer. Which of thefollowing risk factors should the nurse identify as modifiable? (Select all that apply) a) Smoking b) c) Inflammatory bowel disease d) High-fat diet e) Colorectal polyps 25. A nurse is reviewing the laboratory report of a client who has been experiencing a fever for the last 3 days. Which of the following laboratory results indicates the client is experiencing fluid volume deficit? a) Decreased blood urea nitrogen (BUN) b) c) Decreased urine specific gravity d) Increased calcium level 26. A charge nurse discovered that a nurse did not notify the provider that a client’s conditionhad changed. The charge nurse should identify that the nurse is accountable for which of the following torts? a) Negligence b) Slander c) Invasion of privacy d) Libel 27. A nurse is performing a cultural assessment of a group of clients to maintain respect for theirvalue systems and beliefs. Which of the following should the nurse identify as examples of cultural variables? (Select all that apply). a) Eye contact b) Personal space c) Level of education d) Touch e) Blood Type 28. A nurse is admitting a client who has recently developed fever, confusion, and a decreased level of consciousness. Which of the following actions should the nurse take first after obtaining the client’s history and assessment? a) Insert an intravenous catheter to begin fluid therapy b) Develop actions to address the client’s manifestationsc) d) 29. A Identify the client’sDetermine the effectiveness of treatment. needs nurse is planning to administer several medications to a client through a nasogastric (NG) tube. Which of the following actions should the nurse take? a) Mix the medications together and administer through the NG tube . b) Crush the sublingual medication into powder form c) Dissolve crushed tablet medications in sterile water. d) Flush the tube with 5 ml saline between each medication. 30. A nurse is preparing to perform a sterile dressing change for a client who has surgical wound. Which of the following actions should the nurse take to prevent contamination during the dressing change? a) Remove a piece of the new dressing that falls 5cm(2in) from the edge of the sterile fieldduring the dressing change. b) Begin the dressing change by applying sterile gloves and removing the existing dressingc) d) Place the existing dressing on the outermost portion of the sterile field and discard it when the dressing change is finished. 31. A nurse is reviewing the health history of an older adult client who has a hip fracture . The nurse should identify that which of the following findings places the client at risk for developing a pressure injury? a) Osteoporosis b) c) Macular degeneration d) Psoriasis 32. A nurse is performing a focused assessment for a client who has dysrhythmia. Which of thefollowing indicates ineffective cardiac contractions? a) Carotid bruit b) Heart murmur c) d) Bounding radial pulse 33. A nurse is preparing to transfer a client from a chair to the client’s bed. The client can bear partial weight and has upper body strength. Which of the following devices should the nurse to transfer the client? a) A stand-assist lift b) A footboard c) A slide boards d) A mechanical lift with a full body sling 34. A charge nurse is making assignments for the upcoming shift. Which of the following clientassignments should the charge nurse assign to a licensed practical nurse (LPN) a) A client who is to received moderate (conscious) sedation. b) A client who was just admitted with multiple rib fractures c) A client who is scheduled for a bone marrow transplant d) A client who has dehydration and inflammatory bowel disease. 35. A nurse is caring for a client who has a prescription for a narcotic medication. After themedication is administered, the nurse is left with an unused portion. Which of the following actions should the nurse Discard the medication with another nurse as a witnesstake? a) b) Send the remaining medication back to pharmacy c) Place the unused portion of the medication in the sharp’s container. d) Dispose of the unused portion of the medication in the trash. 37. A nurse is caring for an older adult client who has a nonpalpable skin lesion that is less than 0.5cm (0.2 in) in diameter. Which of the following terms should the nurse use to document this finding? a) Papule b) Vesicle c) Nodule d) Macule 1. A nurse is teaching a client about using a continuous positive airway pressure (CPAP) device to treat obstructive sleep apnea. Which of the following information should the nurse include in the teaching? It delivers a present amount of inspiratory pressure at the beginning of each breath It has a continuous adjustment feature that charges the airway pressure throughout the cycle. It delivers a present amount of airway pressure throughout the breathing cycle It delivers positive pressure at the end of each breath 2. A nurse is providing discharge teaching to a client following a heart transplant. Which of the following information should the nurse include in the teaching? Immunosuppressant medications need to be taken for up to 1 year. Shortness of breath might be an indication of transplant rejection The surgical site will heal in 3 to 4 weeks after surgery 3. A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone (SIADH) and is receiving 3 % sodium chloride via continuous IV. Which of the following laboratory finding should the nurse identify as an indication that the SIADH is resolving? Urine specific gravity 1. 020 Sodium 119 mEq/L No tiene pregunta 4. A nurse is teaching a client About fecal occult blood testing (FOBT) for the screening of colorectal cancer. Which of the following statements should the nurse include in the teaching? Your provider will use stool from your digital rectal examination to perform the test Your provider will prescribe a stimulant laxative prior to the procedure to You should begin annual fecal occult blood testing for colorectal cancer screening at 40 years old 5. A nurse is preparing a client for a colonoscopy. Which of the following medications should the nurse anticipate the provider to prescribe as an anesthetic for the procedure? Propofol Pancuronium 6. A nurse is reviewing the medical record of a client who has unstable angina. Which of the findings should the nurse report to the provider? Breath Sounds Temperature 7. A nurse is caring for a client eho has burn injuries covering their upper body and is concerned about thei altered appearance .Which of the following statements should the nurse make ? No aparece la respuesta 8. Anurse is developing a plan of care for a client who will be placed in halo traction following surgical repair of the cervical spine .Which of the following interventions should the nurse include in the plan ? Inspect thi pin site every 48 hr Monitor the client skin under the alo vest . Ensure two personnel hold the halo device when repositioning the client . 9. A nurse is caring for a client who has a traumatic brain injury . Which of the following finding should indicate to the nurse the need for inmediate intervention ¿ Axillary temperature 37.2 C (99F) Apical pulse 100/min Respiratory rate 30/min 10. A nurse is assessing a client who has meningitis. The nurse should edentify which of the following finding as a positive Kerning s sign ? After stroking the lateral área of the foot , the clients toes contract and draw together. After hip flexion, the client is unable to extend their leg complety without pain 11. A nurse is providing discharge teaching to a client who has heart failure an a prescriptionfor furosemide 20 mg PO two time daily. Which of the following instructions should the nurse include in the teaching? Monitor for increased blood pressure Increase intake of high-potassium foods Expect an increase in swelling in the hands and feet. 12. A nurse is providing discharge instructions to a client who has GERD. Which of the following statements by the client demostrates an understanting of the teaching? I should take my medicine with orange juice . Abedtime snack will prevent heartburn 13. A nurse at a provide office is interviewing a client who has multiple sclerosis and has beentaking dantrolone for several months . Which of the following client statements should the nurse identify as an indication that the medication is effective ? I dont have muscle spasms as frequently I havent gotten any colds , even throught it is flu season 14. A nurse is assessing a client who reports a posible exposure to HIV. Which of the following finding should the nurse identify as an early manifestation of HIV infection? Stomatitis Fatigue Wasting Syndrome 15. A nurse is teaching a client who has type 1 diabetes mellitus about hypoglycemia .which ofthe following statements by the client indicates an understanting of the teaching? Exercise reduces the risk for hypoglyemia I can skip my insulin when I dont eat I can drink 4 ounces of soda if my blood sugar is low 16. A nure is teaching a client who has hypertension about dietary modifications to help control blood pressure . Which of the following food choices should the nurse recommend as the client to include in their diet ? 1 packet of reconstituted dry onion soup 3 oz of lean cured ham 3 oz of chicken breast 17. A nurse is planning care for a client who as acute pancreatitis .Which of the followinginterventions should the nurse include in the clients plan? Initiate insulin drip Monitor blood glucose levels Continue regular diet as tolerated