Capstone Exam 2 Review: Key Concepts for Nursing Care and Interventions
Capstone Exam 2 Review: Key Concepts for Nursing Care
and Interventions
Capstone Unit Exam 2 Review
GERD
A patient who has gastroesophageal reflux disease (GERD) is experiencing increasing discomfort.
Which patient statement to the nurse indicates that additional teaching about GERD is needed?
“I eat small meals and have a bedtime snack”
Gastritis
A patient vomiting blood-streaked fluid is admitted to the hospital with acute gastritis. What should
the nurse ask the patient to determine possible risk factors for gastritis?
a. The amount of saturated fat in the diet
b. A family history of gastric or colon cancer
c. Use of non-steroidal anti-inflammatory drugs
d. A history of large recent weight gain or loss
C-diff
Which action will the nurse include in the plan of care for a patient who is being admitted with
Clostridium difficile?
a. Teach the patient about proper food storage
b. Order a diet without any dairy products for the patient
c. Place the client in a private room for contact isolation
d. Teach the patient about why antibiotics will not be used
E-coli
Loperamide
-Do not eat raw food it needs to be cooked
Hepatitis C (Prevent needle Stick)
Hepatitis A (SATA: What to avoid/Intervention)
-Fecal
-Oral
-Wash hands
-No sea food
-Clean toilets
The nurse and a student nurse are discussing the specific points about infants born to HBsAg-
positive mothers. Which of these comments by the student indicates a need for clarification of
information?
"The third dose should be given at least 16 weeks from the second dose."
A client with hepatitis A (HAV) is newly admitted to the unit. Which action would be the priority
to include in this client’s plan of care within the initial 24 hours?
C) Wear gown and gloves during client contact
Capstone Exam 2 Review: Key Concepts for Nursing Care and Interventions
,Capstone Exam 2 Review: Key Concepts for Nursing Care and Interventions
1
Capstone Exam 2 Review: Key Concepts for Nursing Care and Interventions
, Capstone Exam 2 Review: Key Concepts for Nursing Care and Interventions
Crohn’s disease
Private room
Low fiber diet
A client with Crohn's disease is scheduled to receive an infusion of infliximab (Remicade). The
nurse assisting in caring for the client should take which action to monitor the effectiveness of
treatment?
1. Monitoring the leukocyte count for 2 days after the infusion
2. Checking the frequency and consistency of bowel movements
3. Checking serum liver enzyme levels before and after the infusion
4. Carrying out a Hematest on gastric fluids after the infusion is completed
Notes
definition and etiology
• inflammation of segments of bowel, especially ileum, jejunum, and colon, with
areas of normal bowel between inflamed bowel (cobblestone appearance)
Medical management - rest
• nutritional support NPO during acute exacerbation
Ileostomy (What common Problem? *Fluid/Electrolyte)
A client has just had surgery to create an ileostomy. The nurse assesses the client in the
immediate postoperative period for which most frequent complication of this type of surgery?
a.Folate deficiency
b.Malabsorption of fat
c.Intestinal obstruction
d.Fluid and electrolyte imbalance
The nurses on a unit are planning for stoma care for clients who have a stoma for fecal diversion.
Which stomal diversion poses the highest risk for skin breakdown
A) Ileostomy
The nurse is caring for a client with a sigmoid colostomy who requests assistance in removing
the flatus from a 1-piece drainable ostomy pouch. Which is the correct intervention?
B) Opening the bottom of the pouch, allowing the flatus to be expelled
Ostomy (What should a stoma look like? *Red and Moist)
A nurse is assessing the stoma of a client with an ostomy. What would the nurse assess in a
normal, healthy stoma?
D) Red and moist
The nurse is caring for a client with a colostomy pouch. During a teaching session, the nurse
appropriately recommends that the pouch be emptied
a) when it is 1/3 to 1/2 full
Notes
Ruby Red or normal pink and moist withing the first 72 hours (will always stay red due to the
rich supply of blood lining the intestine)
NEVER dark or purple, this means circulation is compromised, will lead to necrosis (tissue
death)
2
Capstone Exam 2 Review: Key Concepts for Nursing Care and Interventions
Capstone Exam 2 Review: Key Concepts for Nursing Care
and Interventions
Capstone Unit Exam 2 Review
GERD
A patient who has gastroesophageal reflux disease (GERD) is experiencing increasing discomfort.
Which patient statement to the nurse indicates that additional teaching about GERD is needed?
“I eat small meals and have a bedtime snack”
Gastritis
A patient vomiting blood-streaked fluid is admitted to the hospital with acute gastritis. What should
the nurse ask the patient to determine possible risk factors for gastritis?
a. The amount of saturated fat in the diet
b. A family history of gastric or colon cancer
c. Use of non-steroidal anti-inflammatory drugs
d. A history of large recent weight gain or loss
C-diff
Which action will the nurse include in the plan of care for a patient who is being admitted with
Clostridium difficile?
a. Teach the patient about proper food storage
b. Order a diet without any dairy products for the patient
c. Place the client in a private room for contact isolation
d. Teach the patient about why antibiotics will not be used
E-coli
Loperamide
-Do not eat raw food it needs to be cooked
Hepatitis C (Prevent needle Stick)
Hepatitis A (SATA: What to avoid/Intervention)
-Fecal
-Oral
-Wash hands
-No sea food
-Clean toilets
The nurse and a student nurse are discussing the specific points about infants born to HBsAg-
positive mothers. Which of these comments by the student indicates a need for clarification of
information?
"The third dose should be given at least 16 weeks from the second dose."
A client with hepatitis A (HAV) is newly admitted to the unit. Which action would be the priority
to include in this client’s plan of care within the initial 24 hours?
C) Wear gown and gloves during client contact
Capstone Exam 2 Review: Key Concepts for Nursing Care and Interventions
,Capstone Exam 2 Review: Key Concepts for Nursing Care and Interventions
1
Capstone Exam 2 Review: Key Concepts for Nursing Care and Interventions
, Capstone Exam 2 Review: Key Concepts for Nursing Care and Interventions
Crohn’s disease
Private room
Low fiber diet
A client with Crohn's disease is scheduled to receive an infusion of infliximab (Remicade). The
nurse assisting in caring for the client should take which action to monitor the effectiveness of
treatment?
1. Monitoring the leukocyte count for 2 days after the infusion
2. Checking the frequency and consistency of bowel movements
3. Checking serum liver enzyme levels before and after the infusion
4. Carrying out a Hematest on gastric fluids after the infusion is completed
Notes
definition and etiology
• inflammation of segments of bowel, especially ileum, jejunum, and colon, with
areas of normal bowel between inflamed bowel (cobblestone appearance)
Medical management - rest
• nutritional support NPO during acute exacerbation
Ileostomy (What common Problem? *Fluid/Electrolyte)
A client has just had surgery to create an ileostomy. The nurse assesses the client in the
immediate postoperative period for which most frequent complication of this type of surgery?
a.Folate deficiency
b.Malabsorption of fat
c.Intestinal obstruction
d.Fluid and electrolyte imbalance
The nurses on a unit are planning for stoma care for clients who have a stoma for fecal diversion.
Which stomal diversion poses the highest risk for skin breakdown
A) Ileostomy
The nurse is caring for a client with a sigmoid colostomy who requests assistance in removing
the flatus from a 1-piece drainable ostomy pouch. Which is the correct intervention?
B) Opening the bottom of the pouch, allowing the flatus to be expelled
Ostomy (What should a stoma look like? *Red and Moist)
A nurse is assessing the stoma of a client with an ostomy. What would the nurse assess in a
normal, healthy stoma?
D) Red and moist
The nurse is caring for a client with a colostomy pouch. During a teaching session, the nurse
appropriately recommends that the pouch be emptied
a) when it is 1/3 to 1/2 full
Notes
Ruby Red or normal pink and moist withing the first 72 hours (will always stay red due to the
rich supply of blood lining the intestine)
NEVER dark or purple, this means circulation is compromised, will lead to necrosis (tissue
death)
2
Capstone Exam 2 Review: Key Concepts for Nursing Care and Interventions
