RNSG 2331 EXAM 4 CAPSTONE QUESTIONS AND ANSWERS
Question:
The client has been working on weight loss for 8 months and has been successful in
losing 35 lbs (15.9 kg). The client is now entering the maintenance phase of the health
promotion plan. Which strategies are important for the nurse to emphasize as the client
enters this phase?
You answered this question Correctly
1. On-going support from weight-loss program personnel.
2. Periodic weigh-ins with the nurse.
3. Discontinue programmatic exercise plan.
4. Relapse prevention plan.
5. Continued peer support.
Rationale
Strategies
1., 2., 4. & 5. Correct: The person must have ongoing support to prevent a relapse. The
weigh-ins increase accountability for prolonged behavioral change. Anytime that a new
behavior is instituted, there is a chance that the person will return to old habits.
Having a plan in place may help the person to stay on track. Ongoing peer support can
be very helpful as the client continues in the maintenance phase.
3. Incorrect: Programmatic exercise, although reduced in frequency perhaps, should still
be available. If this is taken away or reduced too much, the client may return to old
habits.
Question:
Which client in the Labor, Delivery, Recovery, and Postpartum Unit (LDRP) should
the nurse see first?
You answered this question Correctly
1. Primipara at 39 weeks gestation, who is dilated to three centimeters and at minus two
station who states, "I think my water just broke."
2. Multigravida at term who is dilated to six centimers and at minus one station with
moderate contractions every five to ten minutes.
3. Primipara at 38 weeks gestation who is dilated to five centimeters and at zero station
with strong contractions every four minutes.
4. Multigravida at 36 weeks gestation with pregestational diabetes in for a biophysical
profile for fetal well being.
, Rationale
Strategies
1. Correct: Minus two station is high with the presenting part not engaged. This client
is at high risk for prolapsed cord, which would require relieving pressure on the cord and
emergency cesarean delivery.
2. Incorrect: Contractions are not close enough for this client to be an emergent
situation. Also, since this is a multigravida client and not fully dilated yet, she is not a
high risk client.
3. Incorrect: This client is in the active phase of labor, but there is much work to be
done before she is fully dilated and engaged for delivery.
4. Incorrect: This client is not in labor and is a non-emergent client, particularly
compared to client #1.
Question:
The nurse is preparing to discharge a client who has been placed on tranylcypromine.
The nurse teaches the client about food to avoid while taking this medication. What
food choice by the client confirms appropriate understanding of the teaching?
You answered this question Correctly
1. Cottage cheese
2. Salami
3. Baked chicken
4. Potatoes
Rationale
Strategies
2. Correct: The client taking a monoamine oxidase inhibitor (MAOI) such as
tranylcypromine should avoid foods rich in tyramine or tryptophan. These include:
cured foods, those that have been aged, pickled, fermented, or smoked. These can
precipitate a hypertensive crisis.
1. Incorrect: Clients taking MAOIs can eat cottage cheese in reasonable amounts.
3. Incorrect: Clients taking MAOIs can eat baked chicken.
4. Incorrect: Clients taking MAOIs can eat potatoes.
Question:
What task by the RN should be performed first?
You answered this question Correctly
1. Changing a burn dressing that is scheduled every four hours.
2. Administering scheduled IV antibiotic.
3. Teaching a new diagnosed diabetic about diet and exercise.
, 4. Assessing a newly admitted client.
Rationale
Strategies
4. Correct: The admit assessment should be done first. It is important to initiate the
assessment and physical exam within one hour of being admitted to the unit or floor.
The assessment and plan of care should be completed within 8 hours of admission.
1. Incorrect: The other clients' needs are important, but are scheduled and established
in a routine. These routines can be continued once the new client’s assessment has
been completed.
2. Incorrect: This is not a priority based on the information in the question. The
scheduled IV antibiotic administration can be administered within the appropriate time
frame.
3. Incorrect: A newly diagnosed diabetic is not always ready for teaching, so this is not
priority. The nurse should identify when the client is ready to learn. This teaching
session can occur prior to or after assessing the new client.
Question:
A client is admitted to the intensive care unit after overdosing on meperidine. What is
the nurse's first priority?
You answered this question Incorrectly
1. Maintain continuous cardiac monitoring.
2. Administer naloxone hydrochloride 0.4 mg IV every 2-3 minutes prn.
3. Provide alprazolam 0.25 mg PO PRN.
4. Initiate intravenous fluid resuscitation with lactated ringers at 125 mL/hr.
Rationale
Strategies
2. Correct: The respiratory status of the client takes priority. The administration of
naloxone will block the opioid, initiating a reversal of the central nervous system (CNS)
and respiratory depression.
1. Incorrect: Continuous cardiac monitoring is appropriate, however, airway takes
priority.
3. Incorrect: Alprazolam will worsen respiratory depression. Alprazolam is a
benzodiazepine. The action of this drug may depress the CNS.
4. Incorrect: IV fluids will be initiated, but airway takes priority.
Question:
, A client is admitted to the medical unit with an acute onset of fever, chills and RUQ pain.
Vital signs are: T 99.8°F (37.7°C), P 132, RR 34, B/P 142/82. ABG results are: pH-
7.53, PaCO2 30, HCO3 22. The nurse determines that this client is in what acid/base
imbalance?
You answered this question Correctly
1. Respiratory acidosis
2. Respiratory alkalosis
3. Metabolic acidosis
4. Metabolic alkalosis
Rationale
Strategies
2. Correct: This client has a severe infection. Hyperventilation due to anxiety, pain,
shock, severe infection, fever, and liver failure can lead to respiratory alkalosis. pH >
7.45, PCO2 < 35, HCO3 normal.
1. Incorrect: Not acidosis with hyperventilation and pH of 7.53.
3. Incorrect: Not a metabolic related acid/base imbalance since the HCO3 is in normal
range and is not acidosis.
4. Incorrect: Not a metabolic related acid/base imbalance since the HCO3 is in normal
range.
Question:
A new mother calls the clinic and tells the nurse, “I don’t have any help taking care of
my 3 week old baby. I don’t know what to do. I just feel like I can’t take care of him
anymore. I wish I never had him sometimes. Maybe then my husband would spend
more time at home.” What would be the nurse's best response?
You answered this question Correctly
1. "You are experiencing maternity blues, which will go away on its own."
2. "You are just tired. Tell your husband that you need his help."
3. "Come to the clinic now so that we can help you."
4. "Have you thought about getting a family member to help with the baby?"
Rationale
Strategies
3. Correct: This client is exhibiting signs of postpartum psychosis. Post partum
psychosis is characterized by depressed mood, agitation, indecision, lack of
concentration, guilt, and an abnormal attitude toward bodily functions. There is a lack of
Question:
The client has been working on weight loss for 8 months and has been successful in
losing 35 lbs (15.9 kg). The client is now entering the maintenance phase of the health
promotion plan. Which strategies are important for the nurse to emphasize as the client
enters this phase?
You answered this question Correctly
1. On-going support from weight-loss program personnel.
2. Periodic weigh-ins with the nurse.
3. Discontinue programmatic exercise plan.
4. Relapse prevention plan.
5. Continued peer support.
Rationale
Strategies
1., 2., 4. & 5. Correct: The person must have ongoing support to prevent a relapse. The
weigh-ins increase accountability for prolonged behavioral change. Anytime that a new
behavior is instituted, there is a chance that the person will return to old habits.
Having a plan in place may help the person to stay on track. Ongoing peer support can
be very helpful as the client continues in the maintenance phase.
3. Incorrect: Programmatic exercise, although reduced in frequency perhaps, should still
be available. If this is taken away or reduced too much, the client may return to old
habits.
Question:
Which client in the Labor, Delivery, Recovery, and Postpartum Unit (LDRP) should
the nurse see first?
You answered this question Correctly
1. Primipara at 39 weeks gestation, who is dilated to three centimeters and at minus two
station who states, "I think my water just broke."
2. Multigravida at term who is dilated to six centimers and at minus one station with
moderate contractions every five to ten minutes.
3. Primipara at 38 weeks gestation who is dilated to five centimeters and at zero station
with strong contractions every four minutes.
4. Multigravida at 36 weeks gestation with pregestational diabetes in for a biophysical
profile for fetal well being.
, Rationale
Strategies
1. Correct: Minus two station is high with the presenting part not engaged. This client
is at high risk for prolapsed cord, which would require relieving pressure on the cord and
emergency cesarean delivery.
2. Incorrect: Contractions are not close enough for this client to be an emergent
situation. Also, since this is a multigravida client and not fully dilated yet, she is not a
high risk client.
3. Incorrect: This client is in the active phase of labor, but there is much work to be
done before she is fully dilated and engaged for delivery.
4. Incorrect: This client is not in labor and is a non-emergent client, particularly
compared to client #1.
Question:
The nurse is preparing to discharge a client who has been placed on tranylcypromine.
The nurse teaches the client about food to avoid while taking this medication. What
food choice by the client confirms appropriate understanding of the teaching?
You answered this question Correctly
1. Cottage cheese
2. Salami
3. Baked chicken
4. Potatoes
Rationale
Strategies
2. Correct: The client taking a monoamine oxidase inhibitor (MAOI) such as
tranylcypromine should avoid foods rich in tyramine or tryptophan. These include:
cured foods, those that have been aged, pickled, fermented, or smoked. These can
precipitate a hypertensive crisis.
1. Incorrect: Clients taking MAOIs can eat cottage cheese in reasonable amounts.
3. Incorrect: Clients taking MAOIs can eat baked chicken.
4. Incorrect: Clients taking MAOIs can eat potatoes.
Question:
What task by the RN should be performed first?
You answered this question Correctly
1. Changing a burn dressing that is scheduled every four hours.
2. Administering scheduled IV antibiotic.
3. Teaching a new diagnosed diabetic about diet and exercise.
, 4. Assessing a newly admitted client.
Rationale
Strategies
4. Correct: The admit assessment should be done first. It is important to initiate the
assessment and physical exam within one hour of being admitted to the unit or floor.
The assessment and plan of care should be completed within 8 hours of admission.
1. Incorrect: The other clients' needs are important, but are scheduled and established
in a routine. These routines can be continued once the new client’s assessment has
been completed.
2. Incorrect: This is not a priority based on the information in the question. The
scheduled IV antibiotic administration can be administered within the appropriate time
frame.
3. Incorrect: A newly diagnosed diabetic is not always ready for teaching, so this is not
priority. The nurse should identify when the client is ready to learn. This teaching
session can occur prior to or after assessing the new client.
Question:
A client is admitted to the intensive care unit after overdosing on meperidine. What is
the nurse's first priority?
You answered this question Incorrectly
1. Maintain continuous cardiac monitoring.
2. Administer naloxone hydrochloride 0.4 mg IV every 2-3 minutes prn.
3. Provide alprazolam 0.25 mg PO PRN.
4. Initiate intravenous fluid resuscitation with lactated ringers at 125 mL/hr.
Rationale
Strategies
2. Correct: The respiratory status of the client takes priority. The administration of
naloxone will block the opioid, initiating a reversal of the central nervous system (CNS)
and respiratory depression.
1. Incorrect: Continuous cardiac monitoring is appropriate, however, airway takes
priority.
3. Incorrect: Alprazolam will worsen respiratory depression. Alprazolam is a
benzodiazepine. The action of this drug may depress the CNS.
4. Incorrect: IV fluids will be initiated, but airway takes priority.
Question:
, A client is admitted to the medical unit with an acute onset of fever, chills and RUQ pain.
Vital signs are: T 99.8°F (37.7°C), P 132, RR 34, B/P 142/82. ABG results are: pH-
7.53, PaCO2 30, HCO3 22. The nurse determines that this client is in what acid/base
imbalance?
You answered this question Correctly
1. Respiratory acidosis
2. Respiratory alkalosis
3. Metabolic acidosis
4. Metabolic alkalosis
Rationale
Strategies
2. Correct: This client has a severe infection. Hyperventilation due to anxiety, pain,
shock, severe infection, fever, and liver failure can lead to respiratory alkalosis. pH >
7.45, PCO2 < 35, HCO3 normal.
1. Incorrect: Not acidosis with hyperventilation and pH of 7.53.
3. Incorrect: Not a metabolic related acid/base imbalance since the HCO3 is in normal
range and is not acidosis.
4. Incorrect: Not a metabolic related acid/base imbalance since the HCO3 is in normal
range.
Question:
A new mother calls the clinic and tells the nurse, “I don’t have any help taking care of
my 3 week old baby. I don’t know what to do. I just feel like I can’t take care of him
anymore. I wish I never had him sometimes. Maybe then my husband would spend
more time at home.” What would be the nurse's best response?
You answered this question Correctly
1. "You are experiencing maternity blues, which will go away on its own."
2. "You are just tired. Tell your husband that you need his help."
3. "Come to the clinic now so that we can help you."
4. "Have you thought about getting a family member to help with the baby?"
Rationale
Strategies
3. Correct: This client is exhibiting signs of postpartum psychosis. Post partum
psychosis is characterized by depressed mood, agitation, indecision, lack of
concentration, guilt, and an abnormal attitude toward bodily functions. There is a lack of
