CAPSTONE EXAM 1 ACTUAL EXAM 2023-2024 COMPLETE 70 QUESTIONS AND CORRECT DETAILED ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+

A Nurse is caring for a clients on the med-surg unit. Which client is most at risk to
develop a nosocomial infection?
A- clinet with alcohol abuse admitted for detox
B- Client with Type I diabetes and peripheral neuropathy
C- Client recovering from a choleystectomy
D- Client with full thickness burns, an NG tube and a Foley - ...ANSWER....D- Full
thickness burn, NG tube and Foley
*Think immunosupression and avenues for infection
A nurse is caring for clients in the ICU. Which client may be transferred to the stepdown neuro unit?
A- Client with head injury and seizure
B- Client with an ischemic stroke 4 days ago with confusion
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 - ...ANSWER....Bclient with an ischemic stroke 4 days ago with confusion.
*Think what is normal and what is abnormal- who is most stable
After a change of shift, you are assinged to care for the following clients, Which client
should you assess first?
A- 60 year old client on a ventilator for whom a sterile sputum specimen must be sent to
the lab
B- 55 year old with COPD and a pulse oximetry reading from the previous shift of 90%
C- 70 year old with pneumonia who needs to be started on IV antibiotics
D- 50 year old with asthma who complains of shortness of breath after using a
bronchodilator - ...ANSWER....D- 50 year old with asthma who complains of shortness
of breath after using a brochodilator
*Think ABCs, also not the desired effect of the brochodilator treatment; should be
improved.
The nurse just received report on the surgical ward. Which client should be assessed
first?
A- Peptic ulcer disease scheduled for a laparosopic 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 - ...ANSWER....B- multiple injuries
following a motor vehicle crash
*think who is most unstable
A hospital will receive a large number of clients because of a magor disaster in the city.
Which client can be discharged first?
A- 49 year old female 24 hours postop after hysterectomy
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 -
...ANSWER....B- 66 year old male 5 days post op after total hip replacement
*think who is most stable and would be safest to go home
A nurse just received report on her client's at the first of the shift. Which client should be
assessed first?
A- 45 year old woman with a BP of 90/60 and hot, dry skin
B- 37 year old man with BP 130/70, sleeping quietly in his bed
C- 25 year old woman with fruity breath, excessive thrist and polyphagia
D- 16 year old boy with irritability and tremor - ...ANSWER....C- 25 year old woman with
fruity breath, excessive thirst and polyphagia
*who is showing definite signs of a problem not just questionable ones
The staff nurse receives on her assignment for the shift. Which client should she assess
first?
A- A client reporting a headache with a pain score 3/10
B- A client with frequent watery diarrhea, abdominal 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 -
...ANSWER....B- A client with frequent watery diarrhea, abdominal pain and nausea
*think about dehyration and electrolyte inbalance
The client with COPD tells the CNA that he did not get his annual flu shot this year and
has not had a pneumonia vaccination. You would be sure to instruct the CNA to report
which of these?
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 - ...ANSWER....D- Oral temperature of 38.4
*most indicitive of infection
When assessing a 22-year old client who required emergency surgery and multiple
transfusion 3 days ago, you find that the client looks anxious and has labred
respirations at the rate of 38 breaths/min. The oxygen saturation is 90% with the oxygen
delivery at 6 L/min via nasal cannula. Which action is most apropriate?
A- Increase the flow rate on the oxygen to 10 L/min and reassess the client after about
10 minutes
B- Assis the client in using the incentive spirometer and splint his chest with a pillow
while he coughs
C- Administer the ordered morpine sulfate to the client to decrease his anxiety and
reduce the hyperventilation
D- Switch the client to a nonrebreather mask at 95-100% oxygen and call the physician
to discuss the client's status. - ...ANSWER....D- Switch the client to a nonrebreather
mask at 95-100% O2 and call the physician to discuss the client's status.
*think Breathing/oxygen saturation (delievery)- make sure you don't choose anything
that is bad practice like 10 L on a nasal cannula