CAPSTONE EXAM 1 WITH ELABORATED
ANSWERS
A fNurse fis fcaring ffor fa fclients fon fthe fmed-surg funit. fWhich fclient fis fmost fat frisk fto
fdevelop fa fnosocomial finfection?
A- fclinet fwith falcohol fabuse fadmitted ffor fdetox
B- fClient fwith fType fI fdiabetes fand fperipheral fneuropathy
C- fClient frecovering ffrom fa fcholeystectomy
D- fClient fwith ffull fthickness fburns, fan fNG ftube fand fa fFoley f- fCORRECT✅✅D- fFull
fthickness fburn, fNG ftube fand fFoley
*Think fimmunosupression fand favenues ffor finfection
A fnurse fis fcaring ffor fclients fin fthe fICU. fWhich fclient fmay fbe ftransferred fto fthe fstep-
down fneuro funit?
A- fClient fwith fhead finjury fand fseizure
B- fClient fwith fan fischemic fstroke f4 fdays fago fwith fconfusion
C- fClient fwho fis f1-day fpost fop fafter fa ftransshpenoidal fcraniotomy fwith fa
fcerebrospinal ffluid fleak
D-Client fwith fbacterial fmeningitis fand fa fGlasgow fcoma fsale fof f7 f- fCORRECT✅✅B-
fclient fwith fan fischemic fstroke f4 fdays fago fwith fconfusion.
*Think fwhat fis fnormal fand fwhat fis fabnormal- fwho fis fmost fstable
After fa fchange fof fshift, fyou fare fassinged fto fcare ffor fthe ffollowing fclients, fWhich fclient
fshould fyou fassess ffirst?
A- f60 fyear fold fclient fon fa fventilator ffor fwhom fa fsterile fsputum fspecimen fmust fbe
fsent fto fthe flab
B- f55 fyear fold fwith fCOPD fand fa fpulse foximetry freading ffrom fthe fprevious fshift fof
f90%
C- f70 fyear fold fwith fpneumonia fwho fneeds fto fbe fstarted fon fIV fantibiotics
D- f50 fyear fold fwith fasthma fwho fcomplains fof fshortness fof fbreath fafter fusing fa
fbronchodilator f- fCORRECT✅✅D- f50 fyear fold fwith fasthma fwho fcomplains fof
fshortness fof fbreath fafter fusing fa fbrochodilator
*Think fABCs, falso fnot fthe fdesired feffect fof fthe fbrochodilator ftreatment; fshould fbe
fimproved.
The fnurse fjust freceived freport fon fthe fsurgical fward. fWhich fclient fshould fbe fassessed
ffirst?
A- fPeptic fulcer fdisease fscheduled ffor fa flaparosopic fcholeycystectomy fin f4 fhours
B- fMultiple finjuries fafter fa fmotor fvehicle fcrash
C- fGraves fdisease fscheduled ffor fa fthyroidectomy
, D- fPost-appendectomy fwaiting ffor fdischarge f- fCORRECT✅✅B- fmultiple finjuries
ffollowing fa fmotor fvehicle fcrash
*think fwho fis fmost funstable
A fhospital fwill freceive fa flarge fnumber fof fclients fbecause fof fa fmagor fdisaster fin fthe
fcity. fWhich fclient fcan fbe fdischarged ffirst?
A- f49 fyear fold ffemale f24 fhours fpostop fafter fhysterectomy
B- f66 fyear fold fmale f5 fdays fpost fop fafter ftotal fhip freplacement
C- f79 fyear fold ffemale fadmitted f12 fhours fago fwith fpyrlonephritis
D- f82 fyear fold ffemale fadmitted f5 fdays fago fwith fa fstage f3 fpressure fulcer f-
fCORRECT✅✅B- f66 fyear fold fmale f5 fdays fpost fop fafter ftotal fhip freplacement
*think fwho fis fmost fstable fand fwould fbe fsafest fto fgo fhome
A fnurse fjust freceived freport fon fher fclient's fat fthe ffirst fof fthe fshift. fWhich fclient fshould
fbe fassessed ffirst?
A- f45 fyear fold fwoman fwith fa fBP fof f90/60 fand fhot, fdry fskin
B- f37 fyear fold fman fwith fBP f130/70, fsleeping fquietly fin fhis fbed
C- f25 fyear fold fwoman fwith ffruity fbreath, fexcessive fthrist fand fpolyphagia
D- f16 fyear fold fboy fwith firritability fand ftremor f- fCORRECT✅✅C- f25 fyear fold fwoman
fwith ffruity fbreath, fexcessive fthirst fand fpolyphagia
*who fis fshowing fdefinite fsigns fof fa fproblem fnot fjust fquestionable fones
The fstaff fnurse freceives fon fher fassignment ffor fthe fshift. fWhich fclient fshould fshe
fassess ffirst?
A- fA fclient freporting fa fheadache fwith fa fpain fscore f3/10
B- fA fclient fwith ffrequent fwatery fdiarrhea, fabdominal fpain, fnausea
C- fA fclient fwith frespirations fof f20 fand fO2 fsat fof f94% fon froom fait
D- fA fclient fwith fnausea fafter ftaking foral fcontrast ffor fabdominal fCT fscan f-
fCORRECT✅✅B- fA fclient fwith ffrequent fwatery fdiarrhea, fabdominal fpain fand
fnausea
*think fabout fdehyration fand felectrolyte finbalance
The fclient fwith fCOPD ftells fthe fCNA fthat fhe fdid fnot fget fhis fannual fflu fshot fthis fyear
fand fhas fnot fhad fa fpneumonia fvaccination. fYou fwould fbe fsure fto finstruct fthe fCNA fto
freport fwhich fof fthese?
A- fBlood fpressure fof f152/84 fmmHg
B- fRespiratory frate fof f27 fbreaths fper fminute
C- fHeart frate fof f92 fbeats/min
D- fOral ftemperature fof f38.4 f- fCORRECT✅✅D- fOral ftemperature fof f38.4
*most findicitive fof finfection
ANSWERS
A fNurse fis fcaring ffor fa fclients fon fthe fmed-surg funit. fWhich fclient fis fmost fat frisk fto
fdevelop fa fnosocomial finfection?
A- fclinet fwith falcohol fabuse fadmitted ffor fdetox
B- fClient fwith fType fI fdiabetes fand fperipheral fneuropathy
C- fClient frecovering ffrom fa fcholeystectomy
D- fClient fwith ffull fthickness fburns, fan fNG ftube fand fa fFoley f- fCORRECT✅✅D- fFull
fthickness fburn, fNG ftube fand fFoley
*Think fimmunosupression fand favenues ffor finfection
A fnurse fis fcaring ffor fclients fin fthe fICU. fWhich fclient fmay fbe ftransferred fto fthe fstep-
down fneuro funit?
A- fClient fwith fhead finjury fand fseizure
B- fClient fwith fan fischemic fstroke f4 fdays fago fwith fconfusion
C- fClient fwho fis f1-day fpost fop fafter fa ftransshpenoidal fcraniotomy fwith fa
fcerebrospinal ffluid fleak
D-Client fwith fbacterial fmeningitis fand fa fGlasgow fcoma fsale fof f7 f- fCORRECT✅✅B-
fclient fwith fan fischemic fstroke f4 fdays fago fwith fconfusion.
*Think fwhat fis fnormal fand fwhat fis fabnormal- fwho fis fmost fstable
After fa fchange fof fshift, fyou fare fassinged fto fcare ffor fthe ffollowing fclients, fWhich fclient
fshould fyou fassess ffirst?
A- f60 fyear fold fclient fon fa fventilator ffor fwhom fa fsterile fsputum fspecimen fmust fbe
fsent fto fthe flab
B- f55 fyear fold fwith fCOPD fand fa fpulse foximetry freading ffrom fthe fprevious fshift fof
f90%
C- f70 fyear fold fwith fpneumonia fwho fneeds fto fbe fstarted fon fIV fantibiotics
D- f50 fyear fold fwith fasthma fwho fcomplains fof fshortness fof fbreath fafter fusing fa
fbronchodilator f- fCORRECT✅✅D- f50 fyear fold fwith fasthma fwho fcomplains fof
fshortness fof fbreath fafter fusing fa fbrochodilator
*Think fABCs, falso fnot fthe fdesired feffect fof fthe fbrochodilator ftreatment; fshould fbe
fimproved.
The fnurse fjust freceived freport fon fthe fsurgical fward. fWhich fclient fshould fbe fassessed
ffirst?
A- fPeptic fulcer fdisease fscheduled ffor fa flaparosopic fcholeycystectomy fin f4 fhours
B- fMultiple finjuries fafter fa fmotor fvehicle fcrash
C- fGraves fdisease fscheduled ffor fa fthyroidectomy
, D- fPost-appendectomy fwaiting ffor fdischarge f- fCORRECT✅✅B- fmultiple finjuries
ffollowing fa fmotor fvehicle fcrash
*think fwho fis fmost funstable
A fhospital fwill freceive fa flarge fnumber fof fclients fbecause fof fa fmagor fdisaster fin fthe
fcity. fWhich fclient fcan fbe fdischarged ffirst?
A- f49 fyear fold ffemale f24 fhours fpostop fafter fhysterectomy
B- f66 fyear fold fmale f5 fdays fpost fop fafter ftotal fhip freplacement
C- f79 fyear fold ffemale fadmitted f12 fhours fago fwith fpyrlonephritis
D- f82 fyear fold ffemale fadmitted f5 fdays fago fwith fa fstage f3 fpressure fulcer f-
fCORRECT✅✅B- f66 fyear fold fmale f5 fdays fpost fop fafter ftotal fhip freplacement
*think fwho fis fmost fstable fand fwould fbe fsafest fto fgo fhome
A fnurse fjust freceived freport fon fher fclient's fat fthe ffirst fof fthe fshift. fWhich fclient fshould
fbe fassessed ffirst?
A- f45 fyear fold fwoman fwith fa fBP fof f90/60 fand fhot, fdry fskin
B- f37 fyear fold fman fwith fBP f130/70, fsleeping fquietly fin fhis fbed
C- f25 fyear fold fwoman fwith ffruity fbreath, fexcessive fthrist fand fpolyphagia
D- f16 fyear fold fboy fwith firritability fand ftremor f- fCORRECT✅✅C- f25 fyear fold fwoman
fwith ffruity fbreath, fexcessive fthirst fand fpolyphagia
*who fis fshowing fdefinite fsigns fof fa fproblem fnot fjust fquestionable fones
The fstaff fnurse freceives fon fher fassignment ffor fthe fshift. fWhich fclient fshould fshe
fassess ffirst?
A- fA fclient freporting fa fheadache fwith fa fpain fscore f3/10
B- fA fclient fwith ffrequent fwatery fdiarrhea, fabdominal fpain, fnausea
C- fA fclient fwith frespirations fof f20 fand fO2 fsat fof f94% fon froom fait
D- fA fclient fwith fnausea fafter ftaking foral fcontrast ffor fabdominal fCT fscan f-
fCORRECT✅✅B- fA fclient fwith ffrequent fwatery fdiarrhea, fabdominal fpain fand
fnausea
*think fabout fdehyration fand felectrolyte finbalance
The fclient fwith fCOPD ftells fthe fCNA fthat fhe fdid fnot fget fhis fannual fflu fshot fthis fyear
fand fhas fnot fhad fa fpneumonia fvaccination. fYou fwould fbe fsure fto finstruct fthe fCNA fto
freport fwhich fof fthese?
A- fBlood fpressure fof f152/84 fmmHg
B- fRespiratory frate fof f27 fbreaths fper fminute
C- fHeart frate fof f92 fbeats/min
D- fOral ftemperature fof f38.4 f- fCORRECT✅✅D- fOral ftemperature fof f38.4
*most findicitive fof finfection
