Capstone Exam 1 Home safety for Nurses | 2023/2023
Verified Answers
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 Answ- 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 Answ- 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 Answ- 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 Answ- 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 Answ- 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 Answ- 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 Answ- 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 Answ- D- Oral temperature of 38.4
*most indicitive of infection
Verified Answers
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 Answ- 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 Answ- 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 Answ- 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 Answ- 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 Answ- 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 Answ- 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 Answ- 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 Answ- D- Oral temperature of 38.4
*most indicitive of infection
