NUR 2811 MIDTERM EXAM ICHS NURSING
CAPSTONE EXAM | QUESTIONS AND 100% CORRECT
ANSWERS WITH RATIONALES | LATEST UPDATE
GRADED A+
1. A patient with chronic heart failure reports increasing shortness of breath. Which
finding should the nurse expect?
A. Peripheral edema
B. Bradycardia
C. Hyperactive bowel sounds
D. Decreased respiratory rate
Answer: A. Peripheral edema.
Rationale: Heart failure causes fluid retention, leading to peripheral edema.
2. A nurse is teaching a patient about preventing pressure ulcers. Which action is most
important?
A. Reposition the patient every 2 hours
B. Encourage prolonged sitting
C. Apply lotion once a week
D. Limit fluid intake
Answer: A. Reposition the patient every 2 hours.
Rationale: Frequent repositioning reduces pressure on bony prominences, preventing ulcers.
3. A patient with type 1 diabetes shows confusion, diaphoresis, and tachycardia. What is
the priority intervention?
A. Administer insulin
B. Check blood glucose
C. Encourage exercise
D. Provide dietary teaching
Answer: B. Check blood glucose.
Rationale: Symptoms indicate possible hypoglycemia; blood glucose must be checked
immediately.
4. Which finding indicates infection in a post-operative patient?
A. WBC 15,000/mm³
B. Hemoglobin 14 g/dL
C. Sodium 140 mEq/L
D. Platelet count 250,000/mm³
Answer: A. WBC 15,000/mm³.
Rationale: Elevated WBC count is a sign of infection.
, 5. The nurse is caring for a patient on a ventilator. Which action prevents ventilator-
associated pneumonia?
A. Elevate the head of the bed 30–45°
B. Keep the patient supine
C. Limit oral care to once daily
D. Avoid suctioning
Answer: A. Elevate the head of the bed 30–45°.
Rationale: Elevating the head reduces aspiration risk and prevents pneumonia.
6. A patient receiving furosemide should be monitored for which electrolyte imbalance?
A. Hyperkalemia
B. Hypokalemia
C. Hypernatremia
D. Hypercalcemia
Answer: B. Hypokalemia.
Rationale: Furosemide is a loop diuretic that can cause potassium loss.
7. Which assessment finding suggests hypoxia?
A. Warm, dry skin
B. Confusion and restlessness
C. Bradycardia
D. Polyuria
Answer: B. Confusion and restlessness.
Rationale: Early hypoxia often presents with mental status changes and agitation.
8. A patient with COPD is taught pursed-lip breathing. Which is correct?
A. Exhale rapidly
B. Inhale slowly and exhale through pursed lips
C. Hold breath as long as possible
D. Breathe shallowly
Answer: B. Inhale slowly and exhale through pursed lips.
Rationale: Pursed-lip breathing prevents airway collapse and improves ventilation.
9. A lab result shows WBC 18,000/mm³. What does this indicate?
A. Infection
B. Anemia
C. Electrolyte imbalance
D. Hypovolemia
Answer: A. Infection.
Rationale: Elevated WBCs indicate an inflammatory or infectious process.
10. How long should proper handwashing last?
,A. 5–10 seconds
B. 10–15 seconds
C. 20 seconds
D. 1 minute
Answer: C. 20 seconds.
Rationale: Handwashing for at least 20 seconds removes pathogens effectively.
11. Thick yellow sputum in a pneumonia patient indicates:
A. Viral infection
B. Bacterial infection
C. Allergic reaction
D. Normal secretions
Answer: B. Bacterial infection.
Rationale: Purulent sputum usually suggests a bacterial cause.
12. Hypovolemic shock typically presents with:
A. Bradycardia
B. Tachycardia
C. Hypertension
D. Normal pulse
Answer: B. Tachycardia.
Rationale: The body compensates for low blood volume by increasing heart rate.
13. Which statement by a patient with type 2 diabetes shows understanding?
A. “I can stop oral medications once I feel well.”
B. “Lifestyle changes help manage blood sugar.”
C. “Insulin is always needed immediately.”
D. “All carbohydrates must be avoided.”
Answer: B. “Lifestyle changes help manage blood sugar.”
Rationale: Diet and exercise are critical in controlling type 2 diabetes.
14. Prolonged vomiting most often causes which electrolyte imbalance?
A. Hyperkalemia
B. Hypokalemia
C. Hypernatremia
D. Hypocalcemia
Answer: B. Hypokalemia.
Rationale: Vomiting causes loss of gastric acid and potassium.
15. Chest pain radiating to the left arm is most likely:
A. Gastroenteritis
B. Myocardial infarction
C. Pulmonary embolism
, D. Stroke
Answer: B. Myocardial infarction.
Rationale: Classic MI pain often radiates to the arm, neck, or jaw.
16. Which patient is at greatest risk for pressure ulcers?
A. Mobile 25-year-old
B. Bedridden 75-year-old
C. Ambulatory 50-year-old
D. Outpatient 30-year-old
Answer: B. Bedridden 75-year-old.
Rationale: Immobility and advanced age increase ulcer risk.
17. Which food is highest in sodium for a patient on a low-sodium diet?
A. Fresh fruit
B. Canned soup
C. Rice
D. Oatmeal
Answer: B. Canned soup.
Rationale: Processed foods often contain high sodium.
18. Sudden chest pain and shortness of breath in a patient on heparin may indicate:
A. Document findings
B. Administer diuretic
C. Notify healthcare provider immediately
D. Increase heparin dose
Answer: C. Notify healthcare provider immediately.
Rationale: These symptoms may indicate pulmonary embolism.
19. Correct use of an incentive spirometer includes:
A. Exhale slowly after inhaling
B. Inhale slowly and hold 3–5 seconds
C. Use only when short of breath
D. Blow out forcefully
Answer: B. Inhale slowly and hold 3–5 seconds.
Rationale: Deep inhalation maximizes alveolar expansion and prevents atelectasis.
20. Crackles in lungs of a heart failure patient suggest:
A. Pulmonary edema
B. Pneumothorax
C. Bronchitis
D. Normal lungs
Answer: A. Pulmonary edema.
Rationale: Fluid in alveoli produces crackles.
CAPSTONE EXAM | QUESTIONS AND 100% CORRECT
ANSWERS WITH RATIONALES | LATEST UPDATE
GRADED A+
1. A patient with chronic heart failure reports increasing shortness of breath. Which
finding should the nurse expect?
A. Peripheral edema
B. Bradycardia
C. Hyperactive bowel sounds
D. Decreased respiratory rate
Answer: A. Peripheral edema.
Rationale: Heart failure causes fluid retention, leading to peripheral edema.
2. A nurse is teaching a patient about preventing pressure ulcers. Which action is most
important?
A. Reposition the patient every 2 hours
B. Encourage prolonged sitting
C. Apply lotion once a week
D. Limit fluid intake
Answer: A. Reposition the patient every 2 hours.
Rationale: Frequent repositioning reduces pressure on bony prominences, preventing ulcers.
3. A patient with type 1 diabetes shows confusion, diaphoresis, and tachycardia. What is
the priority intervention?
A. Administer insulin
B. Check blood glucose
C. Encourage exercise
D. Provide dietary teaching
Answer: B. Check blood glucose.
Rationale: Symptoms indicate possible hypoglycemia; blood glucose must be checked
immediately.
4. Which finding indicates infection in a post-operative patient?
A. WBC 15,000/mm³
B. Hemoglobin 14 g/dL
C. Sodium 140 mEq/L
D. Platelet count 250,000/mm³
Answer: A. WBC 15,000/mm³.
Rationale: Elevated WBC count is a sign of infection.
, 5. The nurse is caring for a patient on a ventilator. Which action prevents ventilator-
associated pneumonia?
A. Elevate the head of the bed 30–45°
B. Keep the patient supine
C. Limit oral care to once daily
D. Avoid suctioning
Answer: A. Elevate the head of the bed 30–45°.
Rationale: Elevating the head reduces aspiration risk and prevents pneumonia.
6. A patient receiving furosemide should be monitored for which electrolyte imbalance?
A. Hyperkalemia
B. Hypokalemia
C. Hypernatremia
D. Hypercalcemia
Answer: B. Hypokalemia.
Rationale: Furosemide is a loop diuretic that can cause potassium loss.
7. Which assessment finding suggests hypoxia?
A. Warm, dry skin
B. Confusion and restlessness
C. Bradycardia
D. Polyuria
Answer: B. Confusion and restlessness.
Rationale: Early hypoxia often presents with mental status changes and agitation.
8. A patient with COPD is taught pursed-lip breathing. Which is correct?
A. Exhale rapidly
B. Inhale slowly and exhale through pursed lips
C. Hold breath as long as possible
D. Breathe shallowly
Answer: B. Inhale slowly and exhale through pursed lips.
Rationale: Pursed-lip breathing prevents airway collapse and improves ventilation.
9. A lab result shows WBC 18,000/mm³. What does this indicate?
A. Infection
B. Anemia
C. Electrolyte imbalance
D. Hypovolemia
Answer: A. Infection.
Rationale: Elevated WBCs indicate an inflammatory or infectious process.
10. How long should proper handwashing last?
,A. 5–10 seconds
B. 10–15 seconds
C. 20 seconds
D. 1 minute
Answer: C. 20 seconds.
Rationale: Handwashing for at least 20 seconds removes pathogens effectively.
11. Thick yellow sputum in a pneumonia patient indicates:
A. Viral infection
B. Bacterial infection
C. Allergic reaction
D. Normal secretions
Answer: B. Bacterial infection.
Rationale: Purulent sputum usually suggests a bacterial cause.
12. Hypovolemic shock typically presents with:
A. Bradycardia
B. Tachycardia
C. Hypertension
D. Normal pulse
Answer: B. Tachycardia.
Rationale: The body compensates for low blood volume by increasing heart rate.
13. Which statement by a patient with type 2 diabetes shows understanding?
A. “I can stop oral medications once I feel well.”
B. “Lifestyle changes help manage blood sugar.”
C. “Insulin is always needed immediately.”
D. “All carbohydrates must be avoided.”
Answer: B. “Lifestyle changes help manage blood sugar.”
Rationale: Diet and exercise are critical in controlling type 2 diabetes.
14. Prolonged vomiting most often causes which electrolyte imbalance?
A. Hyperkalemia
B. Hypokalemia
C. Hypernatremia
D. Hypocalcemia
Answer: B. Hypokalemia.
Rationale: Vomiting causes loss of gastric acid and potassium.
15. Chest pain radiating to the left arm is most likely:
A. Gastroenteritis
B. Myocardial infarction
C. Pulmonary embolism
, D. Stroke
Answer: B. Myocardial infarction.
Rationale: Classic MI pain often radiates to the arm, neck, or jaw.
16. Which patient is at greatest risk for pressure ulcers?
A. Mobile 25-year-old
B. Bedridden 75-year-old
C. Ambulatory 50-year-old
D. Outpatient 30-year-old
Answer: B. Bedridden 75-year-old.
Rationale: Immobility and advanced age increase ulcer risk.
17. Which food is highest in sodium for a patient on a low-sodium diet?
A. Fresh fruit
B. Canned soup
C. Rice
D. Oatmeal
Answer: B. Canned soup.
Rationale: Processed foods often contain high sodium.
18. Sudden chest pain and shortness of breath in a patient on heparin may indicate:
A. Document findings
B. Administer diuretic
C. Notify healthcare provider immediately
D. Increase heparin dose
Answer: C. Notify healthcare provider immediately.
Rationale: These symptoms may indicate pulmonary embolism.
19. Correct use of an incentive spirometer includes:
A. Exhale slowly after inhaling
B. Inhale slowly and hold 3–5 seconds
C. Use only when short of breath
D. Blow out forcefully
Answer: B. Inhale slowly and hold 3–5 seconds.
Rationale: Deep inhalation maximizes alveolar expansion and prevents atelectasis.
20. Crackles in lungs of a heart failure patient suggest:
A. Pulmonary edema
B. Pneumothorax
C. Bronchitis
D. Normal lungs
Answer: A. Pulmonary edema.
Rationale: Fluid in alveoli produces crackles.
