NUR 210/NUR210 Final Exam V2 |
Transition to Practice - Capstone Q&A
with Rationale | Fortis College
1. A nurse is assigned to a group of clients. Which client should the nurse assess first using the
ABC priority framework?
A. A client who is 2 hours postoperative and has a blood pressure of 88/50 mmHg.
B. A client with a hip fracture reporting a pain level of 8 out of 10.
C. A client with chronic obstructive pulmonary disease (COPD) and an SpO2 of 91% on
room air.
D. A client with diabetes mellitus whose morning blood glucose is 140 mg/dL.
Correct Answer: A
Expert Explanation: The nurse must prioritize the client with a blood pressure of 88/50
mmHg because it indicates hypotension, which falls under the ‘Circulation’ category of the
ABC framework. This finding suggests potential shock or hemorrhage following surgery
and requires immediate intervention to maintain organ perfusion. Other clients, while
requiring care, do not present with immediate life-threatening physiological instability.
2. A nurse is planning to delegate tasks to an Assistive Personnel (AP). Which task is
appropriate for the nurse to delegate?
A. Assisting a stable client with ambulation to the bathroom.
,B. Evaluating the effectiveness of a client’s pain medication.
C. Performing a sterile dressing change on a central line.
D. Providing discharge instructions to a client with a new diagnosis.
Correct Answer: A
Expert Explanation: Assisting a stable client with ambulation is a standard task that falls
within the scope of practice for an AP. Tasks involving assessment, evaluation, and
education, such as sterile procedures or discharge teaching, must be performed by a
registered nurse. Delegating appropriately ensures that the RN can focus on complex
clinical judgments while the AP supports basic care needs.
3. A nurse is caring for a client who is scheduled for surgery. The client expresses uncertainty
about the procedure. Which action should the nurse take?
A. Notify the surgeon that the client has further questions about the procedure.
B. Explain the risks and benefits of the surgery to the client.
C. Ask the client’s family to convince the client to proceed.
D. Document that the client has given verbal consent and proceed with preparation.
Correct Answer: A
Expert Explanation: It is the surgeon’s legal responsibility to provide informed consent,
which includes explaining the risks, benefits, and alternatives of the procedure. The nurse’s
role is to witness the signature and ensure the client understands the information
, provided. If the client expresses doubt or lack of understanding, the nurse must advocate
for the client by contacting the surgeon to clarify.
4. A charge nurse is observing a newly licensed nurse provide care. Which action by the new
nurse requires intervention?
A. The nurse washes hands before and after client contact.
B. The nurse documents care immediately after it is provided.
C. The nurse uses two client identifiers before administering medication.
D. The nurse shares a client’s diagnosis with a colleague in the cafeteria.
Correct Answer: D
Expert Explanation: Sharing client information in a public area like a cafeteria is a
violation of HIPAA and the client’s right to privacy. Even if the colleague is another
healthcare professional, information should only be shared in private areas and only with
those directly involved in the client’s care. Hand hygiene, using identifiers, and timely
documentation are all standard, correct nursing practices.
5. A nurse manager is discussing ethical principles with the staff. Which of the following is an
example of ‘beneficence’?
A. Holding a client’s hand to provide comfort during a painful procedure.
B. Telling the truth to a client about their prognosis.
C. Treating all clients fairly regardless of their socio-economic status.
Transition to Practice - Capstone Q&A
with Rationale | Fortis College
1. A nurse is assigned to a group of clients. Which client should the nurse assess first using the
ABC priority framework?
A. A client who is 2 hours postoperative and has a blood pressure of 88/50 mmHg.
B. A client with a hip fracture reporting a pain level of 8 out of 10.
C. A client with chronic obstructive pulmonary disease (COPD) and an SpO2 of 91% on
room air.
D. A client with diabetes mellitus whose morning blood glucose is 140 mg/dL.
Correct Answer: A
Expert Explanation: The nurse must prioritize the client with a blood pressure of 88/50
mmHg because it indicates hypotension, which falls under the ‘Circulation’ category of the
ABC framework. This finding suggests potential shock or hemorrhage following surgery
and requires immediate intervention to maintain organ perfusion. Other clients, while
requiring care, do not present with immediate life-threatening physiological instability.
2. A nurse is planning to delegate tasks to an Assistive Personnel (AP). Which task is
appropriate for the nurse to delegate?
A. Assisting a stable client with ambulation to the bathroom.
,B. Evaluating the effectiveness of a client’s pain medication.
C. Performing a sterile dressing change on a central line.
D. Providing discharge instructions to a client with a new diagnosis.
Correct Answer: A
Expert Explanation: Assisting a stable client with ambulation is a standard task that falls
within the scope of practice for an AP. Tasks involving assessment, evaluation, and
education, such as sterile procedures or discharge teaching, must be performed by a
registered nurse. Delegating appropriately ensures that the RN can focus on complex
clinical judgments while the AP supports basic care needs.
3. A nurse is caring for a client who is scheduled for surgery. The client expresses uncertainty
about the procedure. Which action should the nurse take?
A. Notify the surgeon that the client has further questions about the procedure.
B. Explain the risks and benefits of the surgery to the client.
C. Ask the client’s family to convince the client to proceed.
D. Document that the client has given verbal consent and proceed with preparation.
Correct Answer: A
Expert Explanation: It is the surgeon’s legal responsibility to provide informed consent,
which includes explaining the risks, benefits, and alternatives of the procedure. The nurse’s
role is to witness the signature and ensure the client understands the information
, provided. If the client expresses doubt or lack of understanding, the nurse must advocate
for the client by contacting the surgeon to clarify.
4. A charge nurse is observing a newly licensed nurse provide care. Which action by the new
nurse requires intervention?
A. The nurse washes hands before and after client contact.
B. The nurse documents care immediately after it is provided.
C. The nurse uses two client identifiers before administering medication.
D. The nurse shares a client’s diagnosis with a colleague in the cafeteria.
Correct Answer: D
Expert Explanation: Sharing client information in a public area like a cafeteria is a
violation of HIPAA and the client’s right to privacy. Even if the colleague is another
healthcare professional, information should only be shared in private areas and only with
those directly involved in the client’s care. Hand hygiene, using identifiers, and timely
documentation are all standard, correct nursing practices.
5. A nurse manager is discussing ethical principles with the staff. Which of the following is an
example of ‘beneficence’?
A. Holding a client’s hand to provide comfort during a painful procedure.
B. Telling the truth to a client about their prognosis.
C. Treating all clients fairly regardless of their socio-economic status.
