Capstone Exam 1
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1. A Nurse is caring for a clients on the med-surg unit. D- Full thickness burn, NG
Which client is most at risk to develop a nosocomial tube and Foley
infection? *Think immunosupression
and avenues for infection
A- clinet with alcohol abuse admitted for detox
B- Client with Type I diabetes and peripheral neuropa-
thy
C- Client recovering from a choleystectomy
D- Client with full thickness burns, an NG tube and a
Foley
2. A nurse is caring for clients in the ICU. Which client may B- client with an ischemic
be transferred to the step-down neuro unit? stroke 4 days ago with
confusion.
A- Client with head injury and seizure *Think what is normal and
B- Client with an ischemic stroke 4 days ago with con- what is abnormal- who is
fusion most stable
C- Client who is 1-day post op after a transshpenoidal
craniotomy with a cerebrospinal fluid leak
D-Client with bacterial meningitis and a Glasgow coma
sale of 7
3. After a change of shift, you are assinged to care for the D- 50 year old with asthma
following clients, Which client should you assess first? who complains of short-
ness of breath after using
A- 60 year old client on a ventilator for whom a sterile a brochodilator
sputum specimen must be sent to the lab *Think ABCs, also not
B- 55 year old with COPD and a pulse oximetry reading the desired effect of the
from the previous shift of 90% brochodilator treatment;
C- 70 year old with pneumonia who needs to be started should be improved.
on IV antibiotics
, Capstone Exam 1
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D- 50 year old with asthma who complains of shortness
of breath after using a bronchodilator
4. The nurse just received report on the surgical ward. B- multiple injuries follow-
Which client should be assessed first? ing a motor vehicle crash
*think who is most unsta-
A- Peptic ulcer disease scheduled for a laparosopic ble
choleycystectomy in 4 hours
B- Multiple injuries after a motor vehicle crash
C- Graves disease scheduled for a thyroidectomy
D- Post-appendectomy waiting for discharge
5. A hospital will receive a large number of clients be- B- 66 year old male 5 days
cause of a magor disaster in the city. Which client can post op after total hip re-
be discharged first? placement
*think who is most stable
A- 49 year old female 24 hours postop after hysterec- and would be safest to go
tomy home
B- 66 year old male 5 days post op after total hip
replacement
C- 79 year old female admitted 12 hours ago with
pyrlonephritis
D- 82 year old female admitted 5 days ago with a stage
3 pressure ulcer
6. A nurse just received report on her client's at the first C- 25 year old woman
of the shift. Which client should be assessed first? with fruity breath, exces-
sive thirst and polyphagia
A- 45 year old woman with a BP of 90/60 and hot, dry *who is showing definite
skin signs of a problem not just
B- 37 year old man with BP 130/70, sleeping quietly in questionable ones
his bed
C- 25 year old woman with fruity breath, excessive
, Capstone Exam 1
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thrist and polyphagia
D- 16 year old boy with irritability and tremor
7. The staff nurse receives on her assignment for the B- A client with frequent
shift. Which client should she assess first? watery diarrhea, abdomi-
nal pain and nausea
A- A client reporting a headache with a pain score 3/10 *think about dehyration
B- A client with frequent watery diarrhea, abdominal and electrolyte inbalance
pain, nausea
C- A client with respirations of 20 and O2 sat of 94% on
room ait
D- A client with nausea after taking oral contrast for
abdominal CT scan
8. The client with COPD tells the CNA that he did not D- Oral temperature of
get his annual flu shot this year and has not had a 38.4
pneumonia vaccination. You would be sure to instruct *most indicitive of infec-
the CNA to report which of these? tion
A- Blood pressure of 152/84 mmHg
B- Respiratory rate of 27 breaths per minute
C- Heart rate of 92 beats/min
D- Oral temperature of 38.4
9. When assessing a 22-year old client who required D- Switch the client to
emergency surgery and multiple transfusion 3 days a nonrebreather mask at
ago, you find that the client looks anxious and has 95-100% O2 and call the
labred respirations at the rate of 38 breaths/min. The physician to discuss the
oxygen saturation is 90% with the oxygen delivery at 6 client's status.
L/min via nasal cannula. Which action is most apropri- *think Breathing/oxygen
ate? saturation (delievery)-
make sure you don't
A- Increase the flow rate on the oxygen to 10 L/min and choose anything that is
Study online at https://quizlet.com/_7vp33l
1. A Nurse is caring for a clients on the med-surg unit. D- Full thickness burn, NG
Which client is most at risk to develop a nosocomial tube and Foley
infection? *Think immunosupression
and avenues for infection
A- clinet with alcohol abuse admitted for detox
B- Client with Type I diabetes and peripheral neuropa-
thy
C- Client recovering from a choleystectomy
D- Client with full thickness burns, an NG tube and a
Foley
2. A nurse is caring for clients in the ICU. Which client may B- client with an ischemic
be transferred to the step-down neuro unit? stroke 4 days ago with
confusion.
A- Client with head injury and seizure *Think what is normal and
B- Client with an ischemic stroke 4 days ago with con- what is abnormal- who is
fusion most stable
C- Client who is 1-day post op after a transshpenoidal
craniotomy with a cerebrospinal fluid leak
D-Client with bacterial meningitis and a Glasgow coma
sale of 7
3. After a change of shift, you are assinged to care for the D- 50 year old with asthma
following clients, Which client should you assess first? who complains of short-
ness of breath after using
A- 60 year old client on a ventilator for whom a sterile a brochodilator
sputum specimen must be sent to the lab *Think ABCs, also not
B- 55 year old with COPD and a pulse oximetry reading the desired effect of the
from the previous shift of 90% brochodilator treatment;
C- 70 year old with pneumonia who needs to be started should be improved.
on IV antibiotics
, Capstone Exam 1
Study online at https://quizlet.com/_7vp33l
D- 50 year old with asthma who complains of shortness
of breath after using a bronchodilator
4. The nurse just received report on the surgical ward. B- multiple injuries follow-
Which client should be assessed first? ing a motor vehicle crash
*think who is most unsta-
A- Peptic ulcer disease scheduled for a laparosopic ble
choleycystectomy in 4 hours
B- Multiple injuries after a motor vehicle crash
C- Graves disease scheduled for a thyroidectomy
D- Post-appendectomy waiting for discharge
5. A hospital will receive a large number of clients be- B- 66 year old male 5 days
cause of a magor disaster in the city. Which client can post op after total hip re-
be discharged first? placement
*think who is most stable
A- 49 year old female 24 hours postop after hysterec- and would be safest to go
tomy home
B- 66 year old male 5 days post op after total hip
replacement
C- 79 year old female admitted 12 hours ago with
pyrlonephritis
D- 82 year old female admitted 5 days ago with a stage
3 pressure ulcer
6. A nurse just received report on her client's at the first C- 25 year old woman
of the shift. Which client should be assessed first? with fruity breath, exces-
sive thirst and polyphagia
A- 45 year old woman with a BP of 90/60 and hot, dry *who is showing definite
skin signs of a problem not just
B- 37 year old man with BP 130/70, sleeping quietly in questionable ones
his bed
C- 25 year old woman with fruity breath, excessive
, Capstone Exam 1
Study online at https://quizlet.com/_7vp33l
thrist and polyphagia
D- 16 year old boy with irritability and tremor
7. The staff nurse receives on her assignment for the B- A client with frequent
shift. Which client should she assess first? watery diarrhea, abdomi-
nal pain and nausea
A- A client reporting a headache with a pain score 3/10 *think about dehyration
B- A client with frequent watery diarrhea, abdominal and electrolyte inbalance
pain, nausea
C- A client with respirations of 20 and O2 sat of 94% on
room ait
D- A client with nausea after taking oral contrast for
abdominal CT scan
8. The client with COPD tells the CNA that he did not D- Oral temperature of
get his annual flu shot this year and has not had a 38.4
pneumonia vaccination. You would be sure to instruct *most indicitive of infec-
the CNA to report which of these? tion
A- Blood pressure of 152/84 mmHg
B- Respiratory rate of 27 breaths per minute
C- Heart rate of 92 beats/min
D- Oral temperature of 38.4
9. When assessing a 22-year old client who required D- Switch the client to
emergency surgery and multiple transfusion 3 days a nonrebreather mask at
ago, you find that the client looks anxious and has 95-100% O2 and call the
labred respirations at the rate of 38 breaths/min. The physician to discuss the
oxygen saturation is 90% with the oxygen delivery at 6 client's status.
L/min via nasal cannula. Which action is most apropri- *think Breathing/oxygen
ate? saturation (delievery)-
make sure you don't
A- Increase the flow rate on the oxygen to 10 L/min and choose anything that is
