NURS 497 | NURS497 Exam 2: Nursing Capstone -
WCU Updated and Latest Questions and Correct
Answers with Rationale
1. A nurse is caring for four clients on a medical-surgical unit. Which client should the nurse
assess first?
A. A client with pneumonia who has become newly confused and restless during the shift
change.
B. A client with chronic obstructive pulmonary disease (COPD) with a pulse oximetry
reading of 91% on room air.
C. A client who had an abdominal cholecystectomy 12 hours ago and reports pain as 6 out
of 10.
D. A client with a history of heart failure reporting a 2-pound weight gain in 24 hours.
Correct Answer: A
Rationale: New-onset confusion and restlessness are early indicators of hypoxia and
potential respiratory failure. While the heart failure client requires monitoring, the
pneumonia patient’s change in mental status indicates an acute deterioration of
oxygenation. Stable COPD patients often maintain lower baseline oxygen levels, making a
91% reading expected for that population. Post-operative pain is expected and can be
managed after addressing the immediate airway and breathing concerns. Prioritizing the
confused client aligns with the ABC framework and ensures patient safety through rapid
intervention.
2. A registered nurse (RN) is delegating tasks to a licensed practical nurse (LPN). Which task is
most appropriate for the RN to delegate?
A. Performing the initial admission assessment on a client with a fractured hip.
B. Evaluating the effectiveness of pain medication for a client with a patient-controlled
analgesia (PCA) pump.
C. Developing a teaching plan for a client newly diagnosed with Type 1 Diabetes.
D. Administering a scheduled dose of subcutaneous insulin to a stable diabetic client.
Correct Answer: D
Rationale: The administration of routine medications like subcutaneous insulin falls
within the scope of practice for an LPN. Initial assessments require the advanced clinical
judgment and diagnostic skills reserved for the RN. Planning and evaluation are core
components of the nursing process that cannot be delegated to vocational staff. The RN
remains responsible for the overall care plan and complex clinical decisions involving
,titration or high-risk devices like PCA pumps. Delegating stable medication tasks allows the
RN to focus on more complex nursing interventions and care coordination.
3. A nurse is planning discharge for a client who had a stroke and has residual right-sided
weakness. Which interdisciplinary team member should be consulted to assist with home
safety and adaptive equipment?
A. Speech-language pathologist
B. Occupational therapist
C. Physical therapist
D. Social worker
Correct Answer: B
Rationale: Occupational therapists specialize in helping clients regain independence with
activities of daily living (ADLs) and selecting adaptive tools. They are the primary resource
for assessing the home environment for safety modifications related to functional tasks.
While physical therapists focus on gross motor skills and gait, the occupational therapist
addresses fine motor skills and home adaptations. Speech-language pathologists focus on
swallowing and communication issues rather than physical home safety. Engaging the
occupational therapist ensures the client can navigate their environment safely and
perform self-care after discharge.
4. A charge nurse is managing conflict between two staff nurses regarding the holiday
schedule. Which conflict resolution strategy involves both parties giving up something to
reach a solution?
A. Collaborating
B. Smoothing
C. Compromising
D. Competing
Correct Answer: C
Rationale: Compromising occurs when each individual agrees to relinquish a portion of
their demands to reach a middle ground. This strategy is often used when both parties have
equal power and time constraints require a quick resolution. Unlike collaboration, which
seeks a win-win outcome where all needs are fully met, compromising results in a partial
win for both. Smoothing downplays the conflict to maintain harmony but does not resolve
the underlying issue. The charge nurse uses compromise to ensure fair staffing while
acknowledging the personal needs of the employees.
5. A nurse is preparing to administer an intramuscular injection to a client. To ensure the
‘right client’ is identified, which action is most appropriate?
A. Ask the client’s roommate to verify the client’s identity.
, B. Check the room number against the medication order in the chart.
C. Compare the client’s name and date of birth on the wristband with the medication
administration record (MAR).
D. Ask the client, ‘Are you Mr. Smith?’ and wait for a verbal confirmation.
D. Ask the client, ‘Are you Mr. Smith?’ and wait for a verbal confirmation.
Correct Answer: C
Rationale: Using two unique identifiers, such as name and date of birth, is the standard for
safe patient identification. The nurse must verify these identifiers against the MAR and the
patient’s ID band simultaneously. Asking a ‘yes or no’ question can lead to errors if the
patient is confused or mishears the nurse. Room numbers are not acceptable identifiers
because patients can be moved frequently within a facility. Strict adherence to the ‘rights of
medication administration’ is critical for preventing sentinel events and ensuring patient
safety.
6. A nurse is assigned to a client with a history of falls. Which intervention is the priority for
the nurse to implement?
A. Ensure the call light is within the client’s reach and provide instructions on its use.
B. Keep the bed in the lowest position with all four side rails raised.
C. Place the client in a room far from the nurses’ station for a quiet environment.
D. Schedule a physical therapy consultation for the next morning.
Correct Answer: A
Rationale: Ensuring the call light is accessible is a fundamental safety intervention that
allows the client to request assistance before attempting to move. Providing instructions
ensures the client understands how to use the device effectively. Placing a high-risk client
far from the nurses’ station is contraindicated as they require closer monitoring. Raising
four side rails is often considered a restraint and can lead to more severe injuries if the
client tries to climb over them. While therapy is helpful, immediate safety measures must
be prioritized upon admission to the unit.
7. A nurse is caring for a client who is being treated for a deep vein thrombosis (DVT). Which
assessment finding requires immediate notification of the healthcare provider?
A. Tenderness and warmth in the affected calf.
B. Ecchymosis at the site of a previous venipuncture.
C. A slight increase in the circumference of the affected leg.
D. Sudden onset of shortness of breath and chest pain.
Correct Answer: D
WCU Updated and Latest Questions and Correct
Answers with Rationale
1. A nurse is caring for four clients on a medical-surgical unit. Which client should the nurse
assess first?
A. A client with pneumonia who has become newly confused and restless during the shift
change.
B. A client with chronic obstructive pulmonary disease (COPD) with a pulse oximetry
reading of 91% on room air.
C. A client who had an abdominal cholecystectomy 12 hours ago and reports pain as 6 out
of 10.
D. A client with a history of heart failure reporting a 2-pound weight gain in 24 hours.
Correct Answer: A
Rationale: New-onset confusion and restlessness are early indicators of hypoxia and
potential respiratory failure. While the heart failure client requires monitoring, the
pneumonia patient’s change in mental status indicates an acute deterioration of
oxygenation. Stable COPD patients often maintain lower baseline oxygen levels, making a
91% reading expected for that population. Post-operative pain is expected and can be
managed after addressing the immediate airway and breathing concerns. Prioritizing the
confused client aligns with the ABC framework and ensures patient safety through rapid
intervention.
2. A registered nurse (RN) is delegating tasks to a licensed practical nurse (LPN). Which task is
most appropriate for the RN to delegate?
A. Performing the initial admission assessment on a client with a fractured hip.
B. Evaluating the effectiveness of pain medication for a client with a patient-controlled
analgesia (PCA) pump.
C. Developing a teaching plan for a client newly diagnosed with Type 1 Diabetes.
D. Administering a scheduled dose of subcutaneous insulin to a stable diabetic client.
Correct Answer: D
Rationale: The administration of routine medications like subcutaneous insulin falls
within the scope of practice for an LPN. Initial assessments require the advanced clinical
judgment and diagnostic skills reserved for the RN. Planning and evaluation are core
components of the nursing process that cannot be delegated to vocational staff. The RN
remains responsible for the overall care plan and complex clinical decisions involving
,titration or high-risk devices like PCA pumps. Delegating stable medication tasks allows the
RN to focus on more complex nursing interventions and care coordination.
3. A nurse is planning discharge for a client who had a stroke and has residual right-sided
weakness. Which interdisciplinary team member should be consulted to assist with home
safety and adaptive equipment?
A. Speech-language pathologist
B. Occupational therapist
C. Physical therapist
D. Social worker
Correct Answer: B
Rationale: Occupational therapists specialize in helping clients regain independence with
activities of daily living (ADLs) and selecting adaptive tools. They are the primary resource
for assessing the home environment for safety modifications related to functional tasks.
While physical therapists focus on gross motor skills and gait, the occupational therapist
addresses fine motor skills and home adaptations. Speech-language pathologists focus on
swallowing and communication issues rather than physical home safety. Engaging the
occupational therapist ensures the client can navigate their environment safely and
perform self-care after discharge.
4. A charge nurse is managing conflict between two staff nurses regarding the holiday
schedule. Which conflict resolution strategy involves both parties giving up something to
reach a solution?
A. Collaborating
B. Smoothing
C. Compromising
D. Competing
Correct Answer: C
Rationale: Compromising occurs when each individual agrees to relinquish a portion of
their demands to reach a middle ground. This strategy is often used when both parties have
equal power and time constraints require a quick resolution. Unlike collaboration, which
seeks a win-win outcome where all needs are fully met, compromising results in a partial
win for both. Smoothing downplays the conflict to maintain harmony but does not resolve
the underlying issue. The charge nurse uses compromise to ensure fair staffing while
acknowledging the personal needs of the employees.
5. A nurse is preparing to administer an intramuscular injection to a client. To ensure the
‘right client’ is identified, which action is most appropriate?
A. Ask the client’s roommate to verify the client’s identity.
, B. Check the room number against the medication order in the chart.
C. Compare the client’s name and date of birth on the wristband with the medication
administration record (MAR).
D. Ask the client, ‘Are you Mr. Smith?’ and wait for a verbal confirmation.
D. Ask the client, ‘Are you Mr. Smith?’ and wait for a verbal confirmation.
Correct Answer: C
Rationale: Using two unique identifiers, such as name and date of birth, is the standard for
safe patient identification. The nurse must verify these identifiers against the MAR and the
patient’s ID band simultaneously. Asking a ‘yes or no’ question can lead to errors if the
patient is confused or mishears the nurse. Room numbers are not acceptable identifiers
because patients can be moved frequently within a facility. Strict adherence to the ‘rights of
medication administration’ is critical for preventing sentinel events and ensuring patient
safety.
6. A nurse is assigned to a client with a history of falls. Which intervention is the priority for
the nurse to implement?
A. Ensure the call light is within the client’s reach and provide instructions on its use.
B. Keep the bed in the lowest position with all four side rails raised.
C. Place the client in a room far from the nurses’ station for a quiet environment.
D. Schedule a physical therapy consultation for the next morning.
Correct Answer: A
Rationale: Ensuring the call light is accessible is a fundamental safety intervention that
allows the client to request assistance before attempting to move. Providing instructions
ensures the client understands how to use the device effectively. Placing a high-risk client
far from the nurses’ station is contraindicated as they require closer monitoring. Raising
four side rails is often considered a restraint and can lead to more severe injuries if the
client tries to climb over them. While therapy is helpful, immediate safety measures must
be prioritized upon admission to the unit.
7. A nurse is caring for a client who is being treated for a deep vein thrombosis (DVT). Which
assessment finding requires immediate notification of the healthcare provider?
A. Tenderness and warmth in the affected calf.
B. Ecchymosis at the site of a previous venipuncture.
C. A slight increase in the circumference of the affected leg.
D. Sudden onset of shortness of breath and chest pain.
Correct Answer: D
