1
CAPSTONE B Actual Proctored Exam
2025 – Verified Questions and Correct
Answers | Graded A+
1. A nurse is caring for a client with a new diagnosis of type 2 diabetes mellitus. Which
action should the nurse prioritize in the initial education plan?
A. Administering insulin therapy
B. Teaching carbohydrate counting
C. Scheduling a follow-up MRI
D. Prescribing an oral hypoglycemic agent
Correct Answer: B
Rationale: Initial education for type 2 diabetes focuses on lifestyle modifications,
including dietary management like carbohydrate counting, to control blood glucose.
Insulin or oral agents may not be immediately required, and an MRI is unrelated.
2. A client with chest pain is admitted to the emergency department. The ECG shows ST
elevation. What is the priority nursing action?
A. Administer oxygen
B. Prepare for thrombolytic therapy
C. Obtain a chest X-ray
D. Draw blood cultures
Correct Answer: A
Rationale: ST elevation indicates acute myocardial infarction. Administering oxygen
improves myocardial oxygenation and is the priority. Thrombolytics may follow, but
oxygen is first. Chest X-ray and blood cultures are not immediate priorities.
3. A nurse is assessing a client with suspected appendicitis. Which finding supports this
diagnosis?
A. Left lower quadrant pain
B. Positive Rovsing’s sign
C. Murphy’s sign
D. Epigastric burning
Correct Answer: B
Rationale: Positive Rovsing’s sign (pain in the right lower quadrant when palpating the
left) supports appendicitis. Left lower quadrant pain suggests diverticulitis, Murphy’s
sign indicates cholecystitis, and epigastric burning suggests ulcers.
4. A client with heart failure reports increased dyspnea and weight gain. What should the
nurse assess first?
A. Blood glucose levels
B. Lung sounds
C. Peripheral pulses
D. Skin turgor
Correct Answer: B
Rationale: Dyspnea and weight gain in heart failure suggest fluid overload. Assessing
, 2
lung sounds for crackles indicates pulmonary edema, a priority. Blood glucose, pulses,
and skin turgor are less urgent.
5. A nurse is preparing to administer a medication via IV push. What is the first step?
A. Flush the IV line with saline
B. Verify the medication dose
C. Check the client’s allergy history
D. Administer the medication slowly
Correct Answer: C
Rationale: Checking for allergies ensures client safety before medication administration.
Verifying the dose and flushing the line follow, and the medication is administered last.
6. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2
L/min via nasal cannula. The client’s SpO2 is 88%. What should the nurse do?
A. Increase oxygen to 4 L/min
B. Notify the provider
C. Encourage deep breathing
D. Switch to a non-rebreather mask
Correct Answer: B
Rationale: An SpO2 of 88% is low for COPD (target 88–92%), indicating potential
respiratory distress. Notifying the provider is appropriate for further evaluation.
Increasing oxygen or changing delivery may require orders, and deep breathing alone
perspective is less immediate.
7. A postoperative client develops a fever and purulent wound drainage. What is the most
likely cause?
A. Atelectasis
B. Surgical site infection
C. Deep vein thrombosis
D. Urinary tract infection
Correct Answer: B
Rationale: Fever and purulent drainage from the wound site indicate a surgical site
infection. Atelectasis causes respiratory symptoms, deep vein thrombosis causes
swelling, and urinary tract infections cause dysuria.
8. A nurse is teaching a client about warfarin therapy. Which statement indicates a need for
further teaching?
A. “I will avoid foods high in vitamin K.”
B. “I will take the medication at the same time daily.”
C. “I can take ibuprofen for pain relief.”
D. “I will report any unusual bruising.”
Correct Answer: C
Rationale: Ibuprofen increases bleeding risk with warfarin due to its antiplatelet effect.
Avoiding vitamin K, consistent timing, and reporting bruising are correct management
strategies.
9. A client with hypertension is prescribed lisinopril. What should the nurse monitor?
A. Serum potassium levels
B. Blood glucose levels
C. Thyroid function tests
D. Liver enzymes
, 3
Correct Answer: A
Rationale: Lisinopril, an ACE inhibitor, can cause hyperkalemia due to reduced
aldosterone. Blood glucose, thyroid, and liver function are not primarily affected.
10. A nurse is caring for a client with a nasogastric tube. What is the priority action before
administering enteral feedings?
A. Check tube placement
B. Elevate the head of the bed
C. Warm the formula
D. Flush the tube with water
Correct Answer: A
Rationale: Verifying tube placement prevents aspiration. Elevating the bed, warming
formula, and flushing the tube are important but secondary to ensuring correct placement.
11. A client with a history of stroke presents with dysphagia. What is the priority nursing
intervention?
A. Administer a thrombolytic
B. Perform a swallow evaluation
C. Initiate tube feeding
D. Order a CT scan
Correct Answer: B
Rationale: Dysphagia post-stroke increases aspiration risk. A swallow evaluation assesses
safety for oral intake. Thrombolytics are for acute stroke, tube feeding may follow
evaluation, and CT is diagnostic, not a nursing intervention.
12. A nurse is assessing a client with suspected pulmonary embolism. Which finding is most
concerning?
A. Heart rate of 80 bpm
B. Oxygen saturation of 85%
C. Respiratory rate of 16 breaths/min
D. Blood pressure of 130/80 mmHg
Correct Answer: B
Rationale: Low oxygen saturation (85%) indicates severe hypoxemia, a hallmark of
pulmonary embolism requiring urgent intervention. Other findings are within normal
limits.
13. A client with atrial fibrillation is prescribed digoxin. What should the nurse teach the
client to monitor?
A. Visual disturbances
B. Joint pain
C. Skin rash
D. Weight loss
Correct Answer: A
Rationale: Digoxin toxicity can cause visual disturbances (e.g., yellow-green vision).
Joint pain, rash, and weight loss are not typical side effects.
14. A nurse is preparing a client for a colonoscopy. Which instruction is most important?
A. Take antibiotics the day before
B. Follow a clear liquid diet for 24 hours prior
C. Avoid all fluids for 12 hours prior
D. Take a sedative the night before
CAPSTONE B Actual Proctored Exam
2025 – Verified Questions and Correct
Answers | Graded A+
1. A nurse is caring for a client with a new diagnosis of type 2 diabetes mellitus. Which
action should the nurse prioritize in the initial education plan?
A. Administering insulin therapy
B. Teaching carbohydrate counting
C. Scheduling a follow-up MRI
D. Prescribing an oral hypoglycemic agent
Correct Answer: B
Rationale: Initial education for type 2 diabetes focuses on lifestyle modifications,
including dietary management like carbohydrate counting, to control blood glucose.
Insulin or oral agents may not be immediately required, and an MRI is unrelated.
2. A client with chest pain is admitted to the emergency department. The ECG shows ST
elevation. What is the priority nursing action?
A. Administer oxygen
B. Prepare for thrombolytic therapy
C. Obtain a chest X-ray
D. Draw blood cultures
Correct Answer: A
Rationale: ST elevation indicates acute myocardial infarction. Administering oxygen
improves myocardial oxygenation and is the priority. Thrombolytics may follow, but
oxygen is first. Chest X-ray and blood cultures are not immediate priorities.
3. A nurse is assessing a client with suspected appendicitis. Which finding supports this
diagnosis?
A. Left lower quadrant pain
B. Positive Rovsing’s sign
C. Murphy’s sign
D. Epigastric burning
Correct Answer: B
Rationale: Positive Rovsing’s sign (pain in the right lower quadrant when palpating the
left) supports appendicitis. Left lower quadrant pain suggests diverticulitis, Murphy’s
sign indicates cholecystitis, and epigastric burning suggests ulcers.
4. A client with heart failure reports increased dyspnea and weight gain. What should the
nurse assess first?
A. Blood glucose levels
B. Lung sounds
C. Peripheral pulses
D. Skin turgor
Correct Answer: B
Rationale: Dyspnea and weight gain in heart failure suggest fluid overload. Assessing
, 2
lung sounds for crackles indicates pulmonary edema, a priority. Blood glucose, pulses,
and skin turgor are less urgent.
5. A nurse is preparing to administer a medication via IV push. What is the first step?
A. Flush the IV line with saline
B. Verify the medication dose
C. Check the client’s allergy history
D. Administer the medication slowly
Correct Answer: C
Rationale: Checking for allergies ensures client safety before medication administration.
Verifying the dose and flushing the line follow, and the medication is administered last.
6. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2
L/min via nasal cannula. The client’s SpO2 is 88%. What should the nurse do?
A. Increase oxygen to 4 L/min
B. Notify the provider
C. Encourage deep breathing
D. Switch to a non-rebreather mask
Correct Answer: B
Rationale: An SpO2 of 88% is low for COPD (target 88–92%), indicating potential
respiratory distress. Notifying the provider is appropriate for further evaluation.
Increasing oxygen or changing delivery may require orders, and deep breathing alone
perspective is less immediate.
7. A postoperative client develops a fever and purulent wound drainage. What is the most
likely cause?
A. Atelectasis
B. Surgical site infection
C. Deep vein thrombosis
D. Urinary tract infection
Correct Answer: B
Rationale: Fever and purulent drainage from the wound site indicate a surgical site
infection. Atelectasis causes respiratory symptoms, deep vein thrombosis causes
swelling, and urinary tract infections cause dysuria.
8. A nurse is teaching a client about warfarin therapy. Which statement indicates a need for
further teaching?
A. “I will avoid foods high in vitamin K.”
B. “I will take the medication at the same time daily.”
C. “I can take ibuprofen for pain relief.”
D. “I will report any unusual bruising.”
Correct Answer: C
Rationale: Ibuprofen increases bleeding risk with warfarin due to its antiplatelet effect.
Avoiding vitamin K, consistent timing, and reporting bruising are correct management
strategies.
9. A client with hypertension is prescribed lisinopril. What should the nurse monitor?
A. Serum potassium levels
B. Blood glucose levels
C. Thyroid function tests
D. Liver enzymes
, 3
Correct Answer: A
Rationale: Lisinopril, an ACE inhibitor, can cause hyperkalemia due to reduced
aldosterone. Blood glucose, thyroid, and liver function are not primarily affected.
10. A nurse is caring for a client with a nasogastric tube. What is the priority action before
administering enteral feedings?
A. Check tube placement
B. Elevate the head of the bed
C. Warm the formula
D. Flush the tube with water
Correct Answer: A
Rationale: Verifying tube placement prevents aspiration. Elevating the bed, warming
formula, and flushing the tube are important but secondary to ensuring correct placement.
11. A client with a history of stroke presents with dysphagia. What is the priority nursing
intervention?
A. Administer a thrombolytic
B. Perform a swallow evaluation
C. Initiate tube feeding
D. Order a CT scan
Correct Answer: B
Rationale: Dysphagia post-stroke increases aspiration risk. A swallow evaluation assesses
safety for oral intake. Thrombolytics are for acute stroke, tube feeding may follow
evaluation, and CT is diagnostic, not a nursing intervention.
12. A nurse is assessing a client with suspected pulmonary embolism. Which finding is most
concerning?
A. Heart rate of 80 bpm
B. Oxygen saturation of 85%
C. Respiratory rate of 16 breaths/min
D. Blood pressure of 130/80 mmHg
Correct Answer: B
Rationale: Low oxygen saturation (85%) indicates severe hypoxemia, a hallmark of
pulmonary embolism requiring urgent intervention. Other findings are within normal
limits.
13. A client with atrial fibrillation is prescribed digoxin. What should the nurse teach the
client to monitor?
A. Visual disturbances
B. Joint pain
C. Skin rash
D. Weight loss
Correct Answer: A
Rationale: Digoxin toxicity can cause visual disturbances (e.g., yellow-green vision).
Joint pain, rash, and weight loss are not typical side effects.
14. A nurse is preparing a client for a colonoscopy. Which instruction is most important?
A. Take antibiotics the day before
B. Follow a clear liquid diet for 24 hours prior
C. Avoid all fluids for 12 hours prior
D. Take a sedative the night before
