CAPSTONE EXAM 1 ACTUAL EXAM 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 An office nurse just checked her secure email. Which message should the nurse return first? A- Multipara at 34 weeks with headache and blurred vision B- Primipara at 22 weeks with supine dizziness C- Primipara at 15 weeks says she has not felt baby move D- Multipara at 12 weeks with white vaginal discharge - ...ANSWER....A- multipara at 34 weeks with headache and blurred vision *this is preeclampsia and that can be life threatening- think in order of severity The nurse is caring for clients in a rural hospital. Which client should be seen first? A- A young child with a sore throat after tonsillectomy B- A client 2 days postpartum with pain during breastfeeding C- A client with a long leg cast with pain after taking vicodin D- A client with pain 2 hours after a liver biopsy - ...ANSWER....C- A client with a long leg cast with pain after taking vicodin *think compartment syndrome The staff nurse just received report for her shift. Which client will she need to assess first? A- A client with a left femur fracture in a cast B- A client complainin of a headache of 2/10 C- A client that had a laryngectomy 5 hours ago D- A client with a lung lobectomy 1 day ago - ...ANSWER....C- A client with a laryngectomy 5 hours ago *concern for airway/laryngospasm