Capstone b
A charge nurse at a long-term care facility ensures that the workload is distributed equally
among staff when making assignments. Wh
following ethical principles is the nurse upholding? - ANS-justice
A charge nurse is observing a newly licensed nurse administer an enteral feeding to a client
who has an established gastrostomy tube. Which of the following actions by the newly
licensed nurse indicates that the charge nurse should intervene? - ANS-The nurse adds food
coloring to the tube feeding.
A newly-licensed nurse tells another nurse that their password has expired and asks for
assistance with inputting data into a client's electronic medical record. Which of the following
statements should the nurse make? - ANS-You won't be able to input any data until you
reset your password."
A nurse at a long-term care facility is caring for a client who has AIDS. The client
accidentally spills the contents of their urinal on the floor. After cleaning up the spill with soap
and water, the nurse should apply a solution of water and which of the following disinfectants
to the floor? - ANS-Bleach
A nurse at a pediatric clinic is checking the vital signs of a 2-week-old infant. Which of the
following findings is outside of the expected reference range? - ANS-BP 64/42 mm Hg
A nurse in a provider's office is reinforcing teaching with a client about performing testicular
self-examination. Which of the following instructions should the nurse include? -
ANS-Examine your testicles after a warm shower."
A nurse is administering the inactivated influenza vaccine to a group of clients at a health
clinic. The nurse should recognize that which of the following conditions is a contraindication
for this vaccine? - ANS-Moderate illness with fever
A nurse is assisting with the admission of a client to an acute-care unit following a suicide
attempt. Which of the following actions should the nurse take first? - ANS-Search the client's
personal belongings.
A nurse is assisting with the admission of a client who is scheduled for surgery. Which of the
following actions should the nurse take? - ANS-Confirm with the client's family that the
consent form has been signed
A nurse is assisting with the care of a client who is in labor with ruptured membranes and
has herpes simplex virus with active lesioi
the following actions should the nurse take? - ANS-Prepare the client for a cesarean birth.
A nurse is assisting with the care of a client who is receiving 1 unit of packed RBs. The client
is coughing and reports a headache and difficulty
breathing. The client's vital signs indicate tachycardia and hypertension. The nurse should
identify that the client is experiencing which of the following types of transfusion reactions? -
ANS-Sepsis
A nurse is caring for a client at a follow-up visit who has been taking lithium therapy for
bipolar disorder. Which of the following findings should
indicate to the nurse that the client is experiencing lithium toxicity? - ANS-Excess salivation
, A nurse is caring for a client who has a compound fracture of the femur. Which of the
following findings should the nurse report to the provider as a manifestation of a fat
embolism? - ANS-Petechia over the client's chest
A nurse is caring for a client who has dementia and is at risk for falls. Which of the following
preventive measures should the nurse take? - ANS-Place the client's bed in the low position.
A nurse is caring for a client who has heart failure and is taking furosemide. Which of the
following statements by the client indicates a need for the nurse to intervene - ANS-I have to
sleep sitting up."
A nurse is caring for a client who has vegetative signs of major depression. Which of the
following actions should the nurse take? - ANS-Provide low-calorie snacks throughout the
day
A nurse is caring for a client who is at 10 weeks of gestation and reports nausea and
vomiting on most days. Which of the following
recommendations should the nurse make? - ANS-"Brush your teeth immediately after
eating."
A nurse is caring for a client who is at 6 weeks of gestation. Which of the following laboratory
findings should the nurse report to the provider? - ANS-Hemoglobin 13 g/dL
A nurse is caring for a client who is postoperative following a mastectomy. Which of the
following actions should the nurse take to help the client cope with the body image change
resulting from the surgery? - ANS-Encourage the client to help care for their surgical
incision.
A nurse is caring for a client who is postpartum and asks the nurse why her newborn
received a vitamin K injection. The nurse should explain that the injection is administered in
order to prevent which of the following complications in the newborn? - ANS-Bleeding
A nurse is caring for a client who is pregnant and Rh-negative. The nurse should plan to
monitor which of the following maternal laboratory test results to determine maternal-fetal
blood incompatibility? - ANS-Erythropoietin
A nurse is caring for a client who is receiving oxygen via nasal cannula at 4 L/min. Which of
the following actions should the nurse take? - ANS-Position the cannula prongs curving
upward in the nose.
A nurse is caring for a preschooler immediately following a tonsillectomy and notices the
child swallowing frequently. Which of the following
actions should the nurse take?. - ANS-obtain the child's vital signs in 15 min.
A nurse is caring of a client who has dementia. Which of the following actions should the
nurse take to promote communication? - ANS-Face the client at eye level when
communicating
A nurse is checking a newborn's Moro reflex. Which of the following actions should the nurse
take to elicit this reflex? - ANS-Stroke the newborn's cheek toward their mouth.
A nurse is collecting data for a client's health history and physical examination. Which of the
following information should the nurse identify as: risk factor for type 2 diabetes mellitus? -
ANS-BMI 32.2
A nurse is collecting data from a 24-month-old toddler during an annual physical
examination. Which of the following findings should the nurse
report to the provider? - ANS-Weighs 12 kg (26.5 Ib)
A nurse is collecting data from a client prior to administration of verapamil. Which of the
following findings indicates a need to withhold the medication? - ANS-Pulse rate 48/min
A nurse is collecting data from a client who has bulimia nervosa. Which of the following
findings should the nurse expect? - ANS-Tooth erosion
A charge nurse at a long-term care facility ensures that the workload is distributed equally
among staff when making assignments. Wh
following ethical principles is the nurse upholding? - ANS-justice
A charge nurse is observing a newly licensed nurse administer an enteral feeding to a client
who has an established gastrostomy tube. Which of the following actions by the newly
licensed nurse indicates that the charge nurse should intervene? - ANS-The nurse adds food
coloring to the tube feeding.
A newly-licensed nurse tells another nurse that their password has expired and asks for
assistance with inputting data into a client's electronic medical record. Which of the following
statements should the nurse make? - ANS-You won't be able to input any data until you
reset your password."
A nurse at a long-term care facility is caring for a client who has AIDS. The client
accidentally spills the contents of their urinal on the floor. After cleaning up the spill with soap
and water, the nurse should apply a solution of water and which of the following disinfectants
to the floor? - ANS-Bleach
A nurse at a pediatric clinic is checking the vital signs of a 2-week-old infant. Which of the
following findings is outside of the expected reference range? - ANS-BP 64/42 mm Hg
A nurse in a provider's office is reinforcing teaching with a client about performing testicular
self-examination. Which of the following instructions should the nurse include? -
ANS-Examine your testicles after a warm shower."
A nurse is administering the inactivated influenza vaccine to a group of clients at a health
clinic. The nurse should recognize that which of the following conditions is a contraindication
for this vaccine? - ANS-Moderate illness with fever
A nurse is assisting with the admission of a client to an acute-care unit following a suicide
attempt. Which of the following actions should the nurse take first? - ANS-Search the client's
personal belongings.
A nurse is assisting with the admission of a client who is scheduled for surgery. Which of the
following actions should the nurse take? - ANS-Confirm with the client's family that the
consent form has been signed
A nurse is assisting with the care of a client who is in labor with ruptured membranes and
has herpes simplex virus with active lesioi
the following actions should the nurse take? - ANS-Prepare the client for a cesarean birth.
A nurse is assisting with the care of a client who is receiving 1 unit of packed RBs. The client
is coughing and reports a headache and difficulty
breathing. The client's vital signs indicate tachycardia and hypertension. The nurse should
identify that the client is experiencing which of the following types of transfusion reactions? -
ANS-Sepsis
A nurse is caring for a client at a follow-up visit who has been taking lithium therapy for
bipolar disorder. Which of the following findings should
indicate to the nurse that the client is experiencing lithium toxicity? - ANS-Excess salivation
, A nurse is caring for a client who has a compound fracture of the femur. Which of the
following findings should the nurse report to the provider as a manifestation of a fat
embolism? - ANS-Petechia over the client's chest
A nurse is caring for a client who has dementia and is at risk for falls. Which of the following
preventive measures should the nurse take? - ANS-Place the client's bed in the low position.
A nurse is caring for a client who has heart failure and is taking furosemide. Which of the
following statements by the client indicates a need for the nurse to intervene - ANS-I have to
sleep sitting up."
A nurse is caring for a client who has vegetative signs of major depression. Which of the
following actions should the nurse take? - ANS-Provide low-calorie snacks throughout the
day
A nurse is caring for a client who is at 10 weeks of gestation and reports nausea and
vomiting on most days. Which of the following
recommendations should the nurse make? - ANS-"Brush your teeth immediately after
eating."
A nurse is caring for a client who is at 6 weeks of gestation. Which of the following laboratory
findings should the nurse report to the provider? - ANS-Hemoglobin 13 g/dL
A nurse is caring for a client who is postoperative following a mastectomy. Which of the
following actions should the nurse take to help the client cope with the body image change
resulting from the surgery? - ANS-Encourage the client to help care for their surgical
incision.
A nurse is caring for a client who is postpartum and asks the nurse why her newborn
received a vitamin K injection. The nurse should explain that the injection is administered in
order to prevent which of the following complications in the newborn? - ANS-Bleeding
A nurse is caring for a client who is pregnant and Rh-negative. The nurse should plan to
monitor which of the following maternal laboratory test results to determine maternal-fetal
blood incompatibility? - ANS-Erythropoietin
A nurse is caring for a client who is receiving oxygen via nasal cannula at 4 L/min. Which of
the following actions should the nurse take? - ANS-Position the cannula prongs curving
upward in the nose.
A nurse is caring for a preschooler immediately following a tonsillectomy and notices the
child swallowing frequently. Which of the following
actions should the nurse take?. - ANS-obtain the child's vital signs in 15 min.
A nurse is caring of a client who has dementia. Which of the following actions should the
nurse take to promote communication? - ANS-Face the client at eye level when
communicating
A nurse is checking a newborn's Moro reflex. Which of the following actions should the nurse
take to elicit this reflex? - ANS-Stroke the newborn's cheek toward their mouth.
A nurse is collecting data for a client's health history and physical examination. Which of the
following information should the nurse identify as: risk factor for type 2 diabetes mellitus? -
ANS-BMI 32.2
A nurse is collecting data from a 24-month-old toddler during an annual physical
examination. Which of the following findings should the nurse
report to the provider? - ANS-Weighs 12 kg (26.5 Ib)
A nurse is collecting data from a client prior to administration of verapamil. Which of the
following findings indicates a need to withhold the medication? - ANS-Pulse rate 48/min
A nurse is collecting data from a client who has bulimia nervosa. Which of the following
findings should the nurse expect? - ANS-Tooth erosion
