NUR2811 ICHS Nursing Capstone
Midterm: 100+ Questions & Answers
1. A nurse is preparing medications for four clients on a medical–surgical unit. Which of the
following clients should the nurse assess first?
A. A client with pneumonia who has a temperature of 38.9°C (102°F) and a respiratory
rate of 26 breaths/min.
B. A client with stable heart failure who reports mild fatigue.
C. A client with well‑controlled hypertension who is ambulating in the hallway.
D. A client with diabetes whose blood sugar is 120 mg/dL before breakfast.
Answer: A
2. A newly licensed nurse is caring for four patients. Which of the following tasks is most
appropriate to delegate to an unlicensed assistive personnel (UAP)?
A. Administering a subcutaneous insulin injection.
B. Providing oral care to a client with a nasogastric tube in place.
C. Assessing lung sounds in a client with newly diagnosed pneumonia.
D. Developing a care plan for a client with multiple chronic conditions.
Answer: B
3. A client with heart failure has a heart rate of 110 beats/min, blood pressure 160/96 mm
Hg, and 3+ pitting edema to the knees. Which of the following best describes the nurse’s
interpretation of these findings?
A. Decompensated heart failure.
B. Stable chronic heart failure.
C. Hypovolemic shock.
D. Cardiac tamponade.
Answer: A
4. A nurse is orienting a student to the concept of delegation. Which of the following
statements best identifies when a task may be appropriately delegated to a UAP?
A. “Delegate only tasks that do not require critical thinking.”
B. “Delegate only if the task is routine and within the UAP’s scope of practice.”
C. “Delegate only if the RN is too busy to perform it.”
D. “Delegate only if the task is simple and non‑invasive.”
Answer: B
5. A client with chronic obstructive pulmonary disease (COPD) is using accessory muscles
to breathe and has an oxygen saturation of 88% on room air. Which of the following
actions should the nurse prioritize first?
A. Administer supplemental oxygen as prescribed.
B. Encourage deep‑breathing and coughing exercises.
C. Increase oral fluid intake.
D. Schedule a chest physiotherapy session.
Answer: A
,6. A nurse is caring for a client who is 2 days postoperative from abdominal surgery and
reports incisional pain rated 8/10. Which of the following is the nurse’s priority nursing
action?
A. Administer the prescribed analgesic and reassess the pain level.
B. Document the pain level in the chart.
C. Notify the surgeon immediately.
D. Encourage deep breathing and repositioning.
Answer: A
7. A nurse is preparing to perform a hand‑off report on a busy unit. Which of the following
communication frameworks is most appropriate to use?
A. SBAR (Situation, Background, Assessment, Recommendation).
B. SOAP (Subjective, Objective, Assessment, Plan).
C. PIE (Problem, Intervention, Evaluation).
D. DATA (Date, Assessment, Treatment, Action).
Answer: A
8. A client with diabetes reports blurred vision and confusion. The nurse checks the blood
glucose and finds it is 48 mg/dL. Which of the following interventions represents the
nurse’s priority action?
A. Administer oral glucose or IV dextrose as ordered.
B. Withhold the next dose of insulin.
C. Reassess the client’s blood glucose in 30 minutes.
D. Document the finding and continue with routine care.
Answer: A
9. A client with a history of falls is preparing to get out of bed. Which of the following actions
by the nurse best promotes patient safety?
A. Placing the bed in the lowest position and locking the wheels.
B. Restricting the client’s mobility to prevent falls.
C. Documenting fall risk in the plan of care.
D. Asking the client to call for help before getting out of bed.
Answer: A
10.A nurse is supervising a UAP who is scheduled to ambulate a client with hypertension.
The UAP states that the client’s blood pressure has been unstable the past shift. Which
of the following should the nurse prioritize first?
A. Reassess the client’s blood pressure and vital signs.
B. Allow the UAP to ambulate the client as scheduled.
C. Postpone ambulation until the evening shift.
D. Ask the client to sit at the bedside for 30 minutes.
Answer: A
11.A client with chronic kidney disease is scheduled for hemodialysis. Which of the
following findings should the nurse report to the healthcare provider immediately?
A. Sudden onset of shortness of breath and chest pain.
B. Slight weight gain since the last treatment.
C. Mild fatigue and lack of appetite.
, D. Dry, itchy skin over the lower extremities.
Answer: A
12.A nurse is caring for a client with suspected sepsis. Which of the following vital sign
changes is most concerning?
A. Temperature 39.2°C (102.6°F).
B. Respiratory rate 28 breaths/min.
C. Systolic blood pressure 88 mm Hg.
D. Heart rate 118 beats/min.
Answer: C
13.A nurse is teaching a client how to self‑administer insulin injections. Which of the
following teaching strategies represents the nurse’s priority?
A. Demonstrate the procedure and then have the client return‑demonstrate.
B. Provide written instructions and ask the client to sign a teaching sheet.
C. Allow the client to practice with a syringe full of medication.
D. Review the adverse effects of insulin before teaching the technique.
Answer: A
14.A client with a history of alcohol abuse arrives in the clinic with confusion, tremors, and
diaphoresis. Which of the following is the nurse’s most likely interpretation?
A. Alcohol withdrawal delirium.
B. Acute pancreatitis.
C. Gastroenteritis.
D. Acute renal failure.
Answer: A
15.A nurse is caring for a client with end‑stage renal disease who is receiving palliative
care. Which of the following best describes the primary goal of nursing care in this
situation?
A. Providing comfort and symptom management.
B. Preventing further kidney damage.
C. Encouraging aggressive dialysis treatments.
D. Administering curative chemotherapy.
Answer: A
16.A client is admitted with a suspected deep vein thrombosis in the right leg. Which of the
following interventions should the nurse prioritize first?
A. Keep the affected leg elevated and avoid massage.
B. Encourage the client to ambulate frequently.
C. Apply warm compresses to the leg.
D. Administer antiplatelet medication as prescribed.
Answer: A
17.A nurse is caring for a client with heart failure who is receiving furosemide. For which of
the following findings should the nurse monitor most closely?
A. Electrolyte imbalances, particularly hypokalemia.
B. Hypertension and bradycardia.
C. Hyperglycemia and polyuria.
Midterm: 100+ Questions & Answers
1. A nurse is preparing medications for four clients on a medical–surgical unit. Which of the
following clients should the nurse assess first?
A. A client with pneumonia who has a temperature of 38.9°C (102°F) and a respiratory
rate of 26 breaths/min.
B. A client with stable heart failure who reports mild fatigue.
C. A client with well‑controlled hypertension who is ambulating in the hallway.
D. A client with diabetes whose blood sugar is 120 mg/dL before breakfast.
Answer: A
2. A newly licensed nurse is caring for four patients. Which of the following tasks is most
appropriate to delegate to an unlicensed assistive personnel (UAP)?
A. Administering a subcutaneous insulin injection.
B. Providing oral care to a client with a nasogastric tube in place.
C. Assessing lung sounds in a client with newly diagnosed pneumonia.
D. Developing a care plan for a client with multiple chronic conditions.
Answer: B
3. A client with heart failure has a heart rate of 110 beats/min, blood pressure 160/96 mm
Hg, and 3+ pitting edema to the knees. Which of the following best describes the nurse’s
interpretation of these findings?
A. Decompensated heart failure.
B. Stable chronic heart failure.
C. Hypovolemic shock.
D. Cardiac tamponade.
Answer: A
4. A nurse is orienting a student to the concept of delegation. Which of the following
statements best identifies when a task may be appropriately delegated to a UAP?
A. “Delegate only tasks that do not require critical thinking.”
B. “Delegate only if the task is routine and within the UAP’s scope of practice.”
C. “Delegate only if the RN is too busy to perform it.”
D. “Delegate only if the task is simple and non‑invasive.”
Answer: B
5. A client with chronic obstructive pulmonary disease (COPD) is using accessory muscles
to breathe and has an oxygen saturation of 88% on room air. Which of the following
actions should the nurse prioritize first?
A. Administer supplemental oxygen as prescribed.
B. Encourage deep‑breathing and coughing exercises.
C. Increase oral fluid intake.
D. Schedule a chest physiotherapy session.
Answer: A
,6. A nurse is caring for a client who is 2 days postoperative from abdominal surgery and
reports incisional pain rated 8/10. Which of the following is the nurse’s priority nursing
action?
A. Administer the prescribed analgesic and reassess the pain level.
B. Document the pain level in the chart.
C. Notify the surgeon immediately.
D. Encourage deep breathing and repositioning.
Answer: A
7. A nurse is preparing to perform a hand‑off report on a busy unit. Which of the following
communication frameworks is most appropriate to use?
A. SBAR (Situation, Background, Assessment, Recommendation).
B. SOAP (Subjective, Objective, Assessment, Plan).
C. PIE (Problem, Intervention, Evaluation).
D. DATA (Date, Assessment, Treatment, Action).
Answer: A
8. A client with diabetes reports blurred vision and confusion. The nurse checks the blood
glucose and finds it is 48 mg/dL. Which of the following interventions represents the
nurse’s priority action?
A. Administer oral glucose or IV dextrose as ordered.
B. Withhold the next dose of insulin.
C. Reassess the client’s blood glucose in 30 minutes.
D. Document the finding and continue with routine care.
Answer: A
9. A client with a history of falls is preparing to get out of bed. Which of the following actions
by the nurse best promotes patient safety?
A. Placing the bed in the lowest position and locking the wheels.
B. Restricting the client’s mobility to prevent falls.
C. Documenting fall risk in the plan of care.
D. Asking the client to call for help before getting out of bed.
Answer: A
10.A nurse is supervising a UAP who is scheduled to ambulate a client with hypertension.
The UAP states that the client’s blood pressure has been unstable the past shift. Which
of the following should the nurse prioritize first?
A. Reassess the client’s blood pressure and vital signs.
B. Allow the UAP to ambulate the client as scheduled.
C. Postpone ambulation until the evening shift.
D. Ask the client to sit at the bedside for 30 minutes.
Answer: A
11.A client with chronic kidney disease is scheduled for hemodialysis. Which of the
following findings should the nurse report to the healthcare provider immediately?
A. Sudden onset of shortness of breath and chest pain.
B. Slight weight gain since the last treatment.
C. Mild fatigue and lack of appetite.
, D. Dry, itchy skin over the lower extremities.
Answer: A
12.A nurse is caring for a client with suspected sepsis. Which of the following vital sign
changes is most concerning?
A. Temperature 39.2°C (102.6°F).
B. Respiratory rate 28 breaths/min.
C. Systolic blood pressure 88 mm Hg.
D. Heart rate 118 beats/min.
Answer: C
13.A nurse is teaching a client how to self‑administer insulin injections. Which of the
following teaching strategies represents the nurse’s priority?
A. Demonstrate the procedure and then have the client return‑demonstrate.
B. Provide written instructions and ask the client to sign a teaching sheet.
C. Allow the client to practice with a syringe full of medication.
D. Review the adverse effects of insulin before teaching the technique.
Answer: A
14.A client with a history of alcohol abuse arrives in the clinic with confusion, tremors, and
diaphoresis. Which of the following is the nurse’s most likely interpretation?
A. Alcohol withdrawal delirium.
B. Acute pancreatitis.
C. Gastroenteritis.
D. Acute renal failure.
Answer: A
15.A nurse is caring for a client with end‑stage renal disease who is receiving palliative
care. Which of the following best describes the primary goal of nursing care in this
situation?
A. Providing comfort and symptom management.
B. Preventing further kidney damage.
C. Encouraging aggressive dialysis treatments.
D. Administering curative chemotherapy.
Answer: A
16.A client is admitted with a suspected deep vein thrombosis in the right leg. Which of the
following interventions should the nurse prioritize first?
A. Keep the affected leg elevated and avoid massage.
B. Encourage the client to ambulate frequently.
C. Apply warm compresses to the leg.
D. Administer antiplatelet medication as prescribed.
Answer: A
17.A nurse is caring for a client with heart failure who is receiving furosemide. For which of
the following findings should the nurse monitor most closely?
A. Electrolyte imbalances, particularly hypokalemia.
B. Hypertension and bradycardia.
C. Hyperglycemia and polyuria.
