Capstone Exam 1 Questions with accurate answers, Graded A+, latest update.

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Capstone Exam 1 Questions with accurate answers, Graded A+, latest update. 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 - ✔✔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 step-down 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 - ✔✔B- client 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 - ✔✔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 - ✔✔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 - ✔✔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 - ✔✔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 - ✔✔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 - ✔✔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. - ✔✔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 - ✔✔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 - ✔✔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 - ✔✔C- A client with a laryngectomy 5 hours ago *concern for airway/laryngospasm As the triage nurse in the emergency department which client would be assessed first? A- 78 year old with an uncontrolled nosebleed B- 36 year old with nausea and comiting for 3 hours C- 6 year old with arm pain after falling off a chair D- 3 year old with a temp of 38.2 - ✔✔A- 78 year old with uncontrolled nosebleed *think most severe, ABCs bleeding=circulation and uncontrolled is bad A nurse is managing clients during an outbreak of Legionnaire's Disease. Which client is most at risk? A- 63 year old with end stage renal disease B- 79 year old with Alzheimer's C- 86 year old with right-sided cerebrovascular accident D- 82 year old with a fractured hip - ✔✔A- 63 year old with end stage renal disease *chronic condition that leads to immunospression- think immunospressed and avenues for infection In the care of clients with pain and discomfort, which task is most appropriate to delegate to the UAP? A- Assissting a client with preparation of a sitz bath B- Monitoring the client for signs of discomfort while ambulation C- Coaching the client to deep breathe during painful procedures D- Evaluating relief after applying a cold compress - ✔✔A- assisting the client with preparation of a sitz bath *UAPs can't assess, teach or evaluate The team is providing emergency care to a client who reveived an excessive dose of narcotic pain medication. Which task is best to delegate to the LPN/LVN? A- Calling the physician and reporting the siuation, using SBAR B- Giving the ordered dose of Narcan and evaluating the response to therapy C- Monitoring the respiratory status for the first 30 minutes D- Applying oxygen per nasal cannula as ordered - ✔✔D- Applying oxygen per the nasal cannula as ordered *LPNs can't evaulate or assess For care of a patient who has oral cancer, which task would be appropriate to delegate to an LPN/LVN? A- Assisting the patient to brush and floss B- Explaining when brushing and flossing are contraindicated C- Giving antacids and sucralfate suspension as ordered D- Recommending saliva substitutes - ✔✔C- Giving Antacids and sucralfate as ordered *LPNs can't teach You are working in an AIDs hospice facility that is also staffed with LPNs and UAPs. Which nursing action will you delegate to the LPN you are supervising? A- Assessing patients' nutritional needs and individualizing diet plans to improve nutrition B- Collecting data about the patients responses to medications used for pain and anorexia C- Teaching the UAPs about how to lower the risk for spreading infections D- Assisting patients with personal hygeine and other activities of daily liging as needed - ✔✔B- Collecting data about the patients responses to medications used for pain and anorexia *LPNs can't asses or teach. They can assist with personal hygeine and activities of daily living but so can a UAP A hospitilized patient with AIDS has a nursing diagnosis of Imbalanced Nutrition: Less than Body Requirements related to nausea and anorexia. Which nursing action is most appropriate to delegate to an LPN who is providing care to this patient? A- Administering oxandrolone 5 mg daily B- Assessing the patient for other nutritional risk factors C- Developing a plan of care to improve the patient's appetite D- Providing instructions about a high-calorie, high protein diet - ✔✔A- administering oxandrolone 5 mg daily *LPNs can't assess, develop care plans or teach The client's nursing diagnosis is deficient fluid volume realted to excessive fluid loss. Which action related to fluid mamagement should be delegated to a UAP? A- Administering IV fluids as prescribed by the physicians B- Providing straws and offering fluids between meals C- Developing a plan for added fluid intake over 24 hours D- Teaching family members to assist the client with fluid intake - ✔✔B- Providing straws and offering fluids between meals [Show More]

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