CAPSTONE FUNDAMENTALS ASSESSMENT
Client with dysphagia, which interventions include in plan - Answers -have the client
seat upright for 1 hr following meals
Assessing Infussion IV site, client reports pain, site is red, warmth.
What the nurse do - Answers -Disontinue Infussion
Routine abdominal assessment. Action by the nurse - Answers -perform palpitation after
ascultation
Teachin new nurses about immunity. Include in the teaching - Answers -The body
produces antibodies in response to an antigen with active immunity
Risk factors for oler adulrs that increase risk of developing infections - Answers -
Lowered immune system function
Teaching Meter dose Inhaler. What instructions teach - Answers -Inhale medication
deeply for 3-5 seconds
A nurse is performing a focused assessment on a client who has a history of COPD and
is experiencing dyspnea, which of the findings should the nurse expect? - Answers -
flaring of the nostrils
A nurse is teaching a client about the correct use of a cane, what should the nurse
include? (SATA) - Answers -ensure the cane has a rubber cap
Hold the can on the stronger side
Flex the elbow slightly when using the cane
Use a quad cane for increased support
1. A nurse is teaching a group of assistive personal about the expected integumentary
changes in older adults, which should the nurse include: - Answers -a. Decreased in
elasticity
1. A nurse in a provider's office is assessing a client who reports a decrease in the
effectiveness of their arthritis medication. Which of the following client information
should the nurse identify as a contributing factor to the decrease in the medication's
effectiveness? - Answers -a. The client has a history of recurring bowel inflammation
1. A nurse is monitoring a client who has been receiving intermittent enteral feedings,
what should the nurse identify as an intolerance to the feeding? - Answers -a. Nausea
1. A nurse is assisting a client who signed an informed consent form for surgery but has
since expressed doubts about the need for surgery, which of the following statements
, should the nurse make? - Answers -The surgeon will answer your questions before
surgery
A nurse is preparing to administer meperidine 35mg IM to an adolescent who is
preoperative. Available in meperidine 50mg how much should the nurse administer?
(Round the to the tenth - Answers -0.7 mg
1. A nurse is documenting client care, which of the following entries should the nurse
identify as an example of implementation of client care? - Answers -a. Contacted the
provider to report client findings
1. A nurse is assisting with meal planning for a client who has been prescribed a
mechanical soft diet. The nurse should instruct the client to avoid which of the following
foods? - Answers -a. Orange slices
1. A nurse is teaching about measures to promote sleep with insomnia, what statement
indicates understanding? - Answers -a. I should reduce my fluid intake to 2 hours before
bedtime
1. A nurse is assessing the pain level of a client who has dementia and difficulty
communicating, which pain assessment technique should the nurse use? - Answers -a.
Behavioral indicators
1. A nurse is performing a cultural assessment of a group of clients to maintain respect
for their value systems and beliefs. Which of the following should the nurse identify as
examples of cultural variables? (SATA) - Answers -a. Eye contact
B. Personal space
C. Touch
1. 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? - Answers -a. Identify the
client's needs
1. A nurse is planning to administer several meds to a client through a ng tube, which
actions should the nurse take? - Answers -a. Dissolve crushed tablet meds in sterile
water (in 15-30 ml sterile water)
1. A nurse is preparing to perform a sterile dressing change for a client who has a
surgical wound. Which of the following actions should the nurse take to prevent
contamination during the dressing change? - Answers -a. Restart the procedure if the
sterile solution splashes onto the sterile field when pouring the solution into the dressing
tray
1. A nurse is admitting a client who has meningococcal meningitis, what should the
nurse do first? - Answers -a. Initiate droplet precaution
Client with dysphagia, which interventions include in plan - Answers -have the client
seat upright for 1 hr following meals
Assessing Infussion IV site, client reports pain, site is red, warmth.
What the nurse do - Answers -Disontinue Infussion
Routine abdominal assessment. Action by the nurse - Answers -perform palpitation after
ascultation
Teachin new nurses about immunity. Include in the teaching - Answers -The body
produces antibodies in response to an antigen with active immunity
Risk factors for oler adulrs that increase risk of developing infections - Answers -
Lowered immune system function
Teaching Meter dose Inhaler. What instructions teach - Answers -Inhale medication
deeply for 3-5 seconds
A nurse is performing a focused assessment on a client who has a history of COPD and
is experiencing dyspnea, which of the findings should the nurse expect? - Answers -
flaring of the nostrils
A nurse is teaching a client about the correct use of a cane, what should the nurse
include? (SATA) - Answers -ensure the cane has a rubber cap
Hold the can on the stronger side
Flex the elbow slightly when using the cane
Use a quad cane for increased support
1. A nurse is teaching a group of assistive personal about the expected integumentary
changes in older adults, which should the nurse include: - Answers -a. Decreased in
elasticity
1. A nurse in a provider's office is assessing a client who reports a decrease in the
effectiveness of their arthritis medication. Which of the following client information
should the nurse identify as a contributing factor to the decrease in the medication's
effectiveness? - Answers -a. The client has a history of recurring bowel inflammation
1. A nurse is monitoring a client who has been receiving intermittent enteral feedings,
what should the nurse identify as an intolerance to the feeding? - Answers -a. Nausea
1. A nurse is assisting a client who signed an informed consent form for surgery but has
since expressed doubts about the need for surgery, which of the following statements
, should the nurse make? - Answers -The surgeon will answer your questions before
surgery
A nurse is preparing to administer meperidine 35mg IM to an adolescent who is
preoperative. Available in meperidine 50mg how much should the nurse administer?
(Round the to the tenth - Answers -0.7 mg
1. A nurse is documenting client care, which of the following entries should the nurse
identify as an example of implementation of client care? - Answers -a. Contacted the
provider to report client findings
1. A nurse is assisting with meal planning for a client who has been prescribed a
mechanical soft diet. The nurse should instruct the client to avoid which of the following
foods? - Answers -a. Orange slices
1. A nurse is teaching about measures to promote sleep with insomnia, what statement
indicates understanding? - Answers -a. I should reduce my fluid intake to 2 hours before
bedtime
1. A nurse is assessing the pain level of a client who has dementia and difficulty
communicating, which pain assessment technique should the nurse use? - Answers -a.
Behavioral indicators
1. A nurse is performing a cultural assessment of a group of clients to maintain respect
for their value systems and beliefs. Which of the following should the nurse identify as
examples of cultural variables? (SATA) - Answers -a. Eye contact
B. Personal space
C. Touch
1. 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? - Answers -a. Identify the
client's needs
1. A nurse is planning to administer several meds to a client through a ng tube, which
actions should the nurse take? - Answers -a. Dissolve crushed tablet meds in sterile
water (in 15-30 ml sterile water)
1. A nurse is preparing to perform a sterile dressing change for a client who has a
surgical wound. Which of the following actions should the nurse take to prevent
contamination during the dressing change? - Answers -a. Restart the procedure if the
sterile solution splashes onto the sterile field when pouring the solution into the dressing
tray
1. A nurse is admitting a client who has meningococcal meningitis, what should the
nurse do first? - Answers -a. Initiate droplet precaution
