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RNSG 2331 EXAM 3 CAPSTONE QUESTIONS AND ANSWERS
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RNSG 2331 EXAM 3 CAPSTONE QUESTIONS AND ANSWERS/RNSG 2331 EXAM 3 CAPSTONE QUESTIONS AND ANSWERS/RNSG 2331 EXAM 3 CAPSTONE QUESTIONS AND ANSWERS
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RNSG 2331 EXAM 3 CAPSTONE QUESTIONS AND ANSWERSQuestion:
Which observations by the nurse indicate that a mother is protecting her two day old
female newborn from infection?
You answered this question Incorrectly
1. Cleans perineum from front to back after newborn soils diaper.
2. Makes certain the umbilical cord remains dry with each diaper change.
3. Places the top of the diaper just above the umbilicus.
4. Wraps sterile petroleum gauze around umbilical cord.
5. Submerges newborn in warm water up to the chest for first bath.
Rationale
Strategies
1., & 2. Correct: Cleaning from front to back will decrease the risk of infection by
reducing the number of microorganisms at the urethral meatus. Keeping the umbilical
cord clean and dry will decrease the risk of infection and will allow it to fall off.
3. Incorrect: The top of the diaper should be placed just below the umbilicus to prevent
exposure to body waste and moisture. Placing the diaper above the umbilical cord will
cause the diaper to rub the umbilicus, which will increase the risk of infection.
4. Incorrect: This would keep the umbilical cord moist and could lead to infection. Also
a sterile dressing is not warranted. The umbilical cord needs to be kept dry so it will fall
off.
5. Incorrect: The newborn should not be placed in water until after the umbilical cord
falls off. Water submersion keeps the cord moist and at risk for infection. The umbilical
cord should be kept dry so that it will fall off.
Question:
A client tells the nurse, “I am dying from cancer. I have told my primary healthcare
provider that I do not want to be revived if my heart stops beating or I stop breathing.”
What action should the nurse take first to assure that the client’s request is respected?
You answered this question Incorrectly
1. Ensure a do-not-resuscitate prescription has been provided.
2. Report client wishes during the end-of-shift report.
3. Have the client sign an advanced directive.
, 4. Ask the client who holds the durable power of attorney for health care decisions.
Rationale
Strategies
1. Correct: The nurse should check the medical record for a DNR order. By law, a
person who does not have a do-not-resuscitate (DNR) prescription, must be provided
CPR in the event of a cardiac/respiratory arrest. This action will ensure the client’s end-
of-life wishes have been communicated and will honor the client’s wishes.
2. Incorrect: It is appropriate to report the client’s end-of-life wishes to other care givers,
but not before ensuring a DNR order is in place.
3. Incorrect: If the client has advance directives, a copy should be placed in the medical
record. However, a DNR prescription must also be in place to ensure the client is not
resuscitated.
4. Incorrect: The client's request can be initiated by notifying the primary healthcare
provider. It would be helpful for the client to have a durable power of attorney.
Question:
A client recently diagnosed with diabetes is sent home with a prescription for
subcutaneous insulin. What statement made by the client indicates that teaching has
been effective regarding safe needle disposal?
You answered this question Correctly
1. "I should wrap the needle in a paper towel and place in the trash."
2. "I should use a hospital issued biohazard container for all needles."
3. "I may use any hard plastic container with a screw-on cap."
4. "I should take my needles to the nearest hospital for disposal. "
Rationale
Strategies
3. Correct: At home, an FDA approved sharps container is not needed, however,
needles, syringes, and sharps may be disposed of in a hard plastic container. Clients
should follow their community guidelines for sharps container disposal. This protects
the sanitation engineers from injury by the sharps.
1. Incorrect: Syringes must be placed in a safe container in order to protect others from
becoming injured by sharps. Wrapping the needle in a paper towel and placing in the
trash increases the possibility of injury to someone.
2. Incorrect: The hospital is not involved in sharps disposal in the home. A hard plastic
container with a screw on cap is an acceptable container to dispose of needles.
, 4. Incorrect: The hospital is not involved in sharps disposal in the home. The client can
dispose of needles safely at home in a hard plastic container with a screw on cap. The
needle should not be brought to the hospital for disposal.
Question:
A 13 year old, found unresponsive in the park, is brought into the emergency
department. The nurse sees a medical alert bracelet stating “Diabetic”, and notes a
fruity smell to the breath. There are no family members available to obtain consent for
treatment and an attempt to call them has been unsuccessful. What action should the
nurse take?
You answered this question Correctly
1. Obtain consent from the social worker on duty in the emergency department.
2. Begin treatment by inserting two large bore IVs of Normal Saline.
3. Give glucogon IM and wait for the arrival of a parent to consent to further treatment.
4. Withhold treatment until a parent arrives to the emergency department.
Rationale
2. Correct: In emergencies, if it is impossible to obtain consent from the client or an
authorized person, a health care provider may perform a procedure required to benefit
the client or save a life without liability for failure to obtain consent. In such cases the
law assumes that the client would wish to be treated. Begin treatment for diabetic ketoacidosis
(DKA).
1. Incorrect: Consent for a minor is not needed in the event of an emergency. The social
worker does not give consent in this situation.
3. Incorrect: This client is exhibiting signs of DKA, so glucagon is not needed.
Emergency treatment can be provided without parental consent.
4. Incorrect: Consent for a minor is not needed in the event of an emergency. This is an
emergency, so begin treatment for DKA.
Question:
The nurse is caring for a client in the emergency department. The primary healthcare
provider prescribed 1000 mL of
D5 ½ NS. The IV is infusing at 25 gtts/min. (Drop factor is 60 gtts/mL). What is the
infusion time in hours? Round your answer to the nearest whole number.
You answered this question CorrectlyEnter the answer for the question below.
Rationale
Strategies
Step 1 1000 x 60 = 25 total fluid x drop factor = infusion time
, x time in minutes
60,000 = 25
x
25x = 60,000
x = 2400 min. divide by 60 = 40 hours
Question:
The nurse is caring for a client in an outpatient clinic. The client is being treated with
warfarin for prevention of a stroke due to atrial fibrillation. The international normalized
ratio (INR) was noted to be 4.6. What should the nurse do?
You answered this question Correctly
1. Inform the primary healthcare provider immediately.
2. Instruct the client to continue medication as ordered.
3. Inform the client to watch for signs of bleeding.
4. Inform the client to return to the clinic per routine monitoring schedule.
5. Take no action as this value is within target range.
Rationale
Strategies
1. & 3. Correct: The primary healthcare provider should be notified. The value of 4 is
above the usual target range of 2-3. The client has a potential for decreased clotting
and bleeding. The client should be told to watch for signs of bleeding.
2. Incorrect: The medication dosage is likely to be reduced.
4. Incorrect: The client should not leave the clinic until the primary healthcare provider
has been notified. Further action is indicated and may include changing the usual
warfarin dosage.
5. Incorrect: The normal range for a INR is 2-3. When a client is prescribed warfarin,
the INR should increase to a therapeutic target range. The value of 4.6 is greater than
the usual target range.
Question:
Which nursing tasks can the RN delegate to an unlicensed assistive personnel (UAP)?
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