NURS 497 | NURS497 Exam 3: Nursing Capstone -
WCU Updated and Latest Questions and Correct
Answers with Rationale
1. A nurse in the emergency department is caring for four clients. Which client should the
nurse assess first?
A. A client with a closed fracture of the right tibia who reports a pain level of 7 out of 10.
B. A client with a history of hypertension who has a blood pressure of 158/92 mmHg.
C. A client with an acute asthma exacerbation who has a pulse oximetry reading of 88% on
room air.
D. A client who has a 2-cm laceration on the forearm with minimal bleeding.
Correct Answer: C
Rationale: Prioritizing care using the ABC framework is essential for patient safety. The
client with an asthma exacerbation and low oxygen saturation indicates a compromise in
breathing that requires immediate intervention. A fracture involves pain but is not
immediately life-threatening compared to hypoxia. Hypertension is a chronic concern and
does not take precedence over an acute respiratory event. Assessing the most unstable
patient first ensures that life-saving measures are implemented promptly.
2. A nurse is planning to delegate tasks to an unlicensed assistive personnel (UAP). Which of
the following tasks is appropriate for the nurse to delegate?
A. Performing a sterile dressing change on a postoperative wound.
B. Measuring and recording the intake and output of a client on telemetry.
C. Assisting a stable client with ambulation for the first time after surgery.
D. Providing discharge instructions to a client who had a cardiac catheterization.
Correct Answer: B
Rationale: Delegation requires the nurse to match the task with the appropriate level of
personnel. Measuring intake and output is a routine, non-invasive task that falls within the
scope of a UAP. Sterile dressing changes and discharge education require specialized
nursing knowledge and clinical judgment. Initial ambulation after surgery requires a
nurse’s assessment to ensure patient stability and safety. The nurse remains accountable
for the overall care provided to the patient even after delegation.
3. The nurse manager is investigating a medication error that occurred on the unit. Which of
the following actions should the nurse manager take first to promote a ‘Just Culture’?
A. Analyze the system processes that contributed to the error.
B. Reprimand the nurse involved to prevent future occurrences.
,C. Report the individual nurse to the State Board of Nursing immediately.
D. Update the policy manual and require all staff to re-read it.
Correct Answer: A
Rationale: A Just Culture focuses on identifying systemic flaws rather than blaming
individuals for human errors. Analyzing the processes allows the manager to understand
why the error occurred and how to prevent it. Punitive actions often lead to
underreporting and do not address the underlying causes of mistakes. Quality
improvement relies on open communication and the willingness to fix broken systems.
This approach fosters an environment of safety and continuous learning for all staff
members.
4. A nurse is using the SBAR communication tool to report a change in a client’s condition to
the provider. Which of the following statements should the nurse include in the ‘A’
(Assessment) portion?
A. ‘I am calling because the client’s heart rate has increased to 120 beats per minute.’
B. ‘The client was admitted yesterday with a diagnosis of heart failure.’
C. ‘I recommend that we start the client on a diuretic medication immediately.’
D. ‘I believe the client is developing pulmonary edema due to fluid overload.’
Correct Answer: D
Rationale: The Assessment component of SBAR involves the nurse’s professional
conclusion about the current situation. Stating that the client is likely developing
pulmonary edema reflects the nurse’s clinical interpretation of the findings. The heart rate
measurement belongs in the Situation or Background section. Recommendations are
reserved for the final portion of the communication tool. Clear assessment statements help
the provider understand the urgency and nature of the clinical problem.
5. A charge nurse is observing a newly licensed nurse perform a sterile procedure. Which of
the following actions by the new nurse requires immediate intervention?
A. Opening the sterile pack away from the body first.
B. Reaching over the sterile field to pick up a gauze pad.
C. Touching the inner surface of the sterile glove with the bare hand.
D. Discarding the top layer of the sterile wrap after opening it.
Correct Answer: B
Rationale: Maintaining a sterile field is critical for preventing healthcare-associated
infections. Reaching over a sterile field contaminates it because microorganisms can fall
from the nurse’s clothing or skin. Sterile items must only be touched by other sterile items
to maintain integrity. The nurse should always work around the perimeter of the field
, rather than across it. Correcting this behavior immediately protects the patient from
potential surgical site infections.
6. A nurse is preparing to administer a high-alert medication. Which of the following safety
strategies should the nurse implement?
A. Ask another nurse to perform an independent double-check of the dosage.
B. Rely on the barcode scanner as the sole method of identification.
C. Keep the medication at the bedside to save time during administration.
D. Verify the client’s identity using only their room number.
Correct Answer: A
Rationale: High-alert medications carry a significant risk of causing serious harm if used in
error. An independent double-check involves two nurses separately verifying the
prescription, calculations, and product. This process reduces the likelihood of human error
reaching the patient. Barcode scanning is a helpful tool but should supplement, not replace,
nursing judgment. Ensuring multiple layers of safety is the hallmark of high-quality patient
care in acute settings.
7. A multidisciplinary team is conducting a Root Cause Analysis (RCA) after a sentinel event.
What is the primary purpose of this process?
A. To identify underlying system failures and prevent future occurrences.
B. To determine the legal liability of the hospital in a lawsuit.
C. To identify which staff member is most responsible for the incident.
D. To provide a report to the insurance company for reimbursement.
Correct Answer: A
Rationale: Root Cause Analysis is a structured method used to look beyond the surface of
an event. It aims to find the latent factors and system vulnerabilities that allowed an error
to happen. The goal is never to assign blame to an individual but to improve safety for all
future patients. By addressing the root cause, the facility can implement changes that make
it harder for the same mistake to recur. Continuous quality improvement depends on the
findings generated from a thorough RCA.
8. A nurse is caring for an older adult client who is at high risk for falls. Which of the following
nursing interventions is the priority?
A. Keep all four side rails up at all times to prevent the client from getting out of bed.
B. Encourage the family to stay with the client around the clock.
C. Place the client’s bed in the lowest position and lock the wheels.
D. Administer a mild sedative to keep the client calm during the night.
WCU Updated and Latest Questions and Correct
Answers with Rationale
1. A nurse in the emergency department is caring for four clients. Which client should the
nurse assess first?
A. A client with a closed fracture of the right tibia who reports a pain level of 7 out of 10.
B. A client with a history of hypertension who has a blood pressure of 158/92 mmHg.
C. A client with an acute asthma exacerbation who has a pulse oximetry reading of 88% on
room air.
D. A client who has a 2-cm laceration on the forearm with minimal bleeding.
Correct Answer: C
Rationale: Prioritizing care using the ABC framework is essential for patient safety. The
client with an asthma exacerbation and low oxygen saturation indicates a compromise in
breathing that requires immediate intervention. A fracture involves pain but is not
immediately life-threatening compared to hypoxia. Hypertension is a chronic concern and
does not take precedence over an acute respiratory event. Assessing the most unstable
patient first ensures that life-saving measures are implemented promptly.
2. A nurse is planning to delegate tasks to an unlicensed assistive personnel (UAP). Which of
the following tasks is appropriate for the nurse to delegate?
A. Performing a sterile dressing change on a postoperative wound.
B. Measuring and recording the intake and output of a client on telemetry.
C. Assisting a stable client with ambulation for the first time after surgery.
D. Providing discharge instructions to a client who had a cardiac catheterization.
Correct Answer: B
Rationale: Delegation requires the nurse to match the task with the appropriate level of
personnel. Measuring intake and output is a routine, non-invasive task that falls within the
scope of a UAP. Sterile dressing changes and discharge education require specialized
nursing knowledge and clinical judgment. Initial ambulation after surgery requires a
nurse’s assessment to ensure patient stability and safety. The nurse remains accountable
for the overall care provided to the patient even after delegation.
3. The nurse manager is investigating a medication error that occurred on the unit. Which of
the following actions should the nurse manager take first to promote a ‘Just Culture’?
A. Analyze the system processes that contributed to the error.
B. Reprimand the nurse involved to prevent future occurrences.
,C. Report the individual nurse to the State Board of Nursing immediately.
D. Update the policy manual and require all staff to re-read it.
Correct Answer: A
Rationale: A Just Culture focuses on identifying systemic flaws rather than blaming
individuals for human errors. Analyzing the processes allows the manager to understand
why the error occurred and how to prevent it. Punitive actions often lead to
underreporting and do not address the underlying causes of mistakes. Quality
improvement relies on open communication and the willingness to fix broken systems.
This approach fosters an environment of safety and continuous learning for all staff
members.
4. A nurse is using the SBAR communication tool to report a change in a client’s condition to
the provider. Which of the following statements should the nurse include in the ‘A’
(Assessment) portion?
A. ‘I am calling because the client’s heart rate has increased to 120 beats per minute.’
B. ‘The client was admitted yesterday with a diagnosis of heart failure.’
C. ‘I recommend that we start the client on a diuretic medication immediately.’
D. ‘I believe the client is developing pulmonary edema due to fluid overload.’
Correct Answer: D
Rationale: The Assessment component of SBAR involves the nurse’s professional
conclusion about the current situation. Stating that the client is likely developing
pulmonary edema reflects the nurse’s clinical interpretation of the findings. The heart rate
measurement belongs in the Situation or Background section. Recommendations are
reserved for the final portion of the communication tool. Clear assessment statements help
the provider understand the urgency and nature of the clinical problem.
5. A charge nurse is observing a newly licensed nurse perform a sterile procedure. Which of
the following actions by the new nurse requires immediate intervention?
A. Opening the sterile pack away from the body first.
B. Reaching over the sterile field to pick up a gauze pad.
C. Touching the inner surface of the sterile glove with the bare hand.
D. Discarding the top layer of the sterile wrap after opening it.
Correct Answer: B
Rationale: Maintaining a sterile field is critical for preventing healthcare-associated
infections. Reaching over a sterile field contaminates it because microorganisms can fall
from the nurse’s clothing or skin. Sterile items must only be touched by other sterile items
to maintain integrity. The nurse should always work around the perimeter of the field
, rather than across it. Correcting this behavior immediately protects the patient from
potential surgical site infections.
6. A nurse is preparing to administer a high-alert medication. Which of the following safety
strategies should the nurse implement?
A. Ask another nurse to perform an independent double-check of the dosage.
B. Rely on the barcode scanner as the sole method of identification.
C. Keep the medication at the bedside to save time during administration.
D. Verify the client’s identity using only their room number.
Correct Answer: A
Rationale: High-alert medications carry a significant risk of causing serious harm if used in
error. An independent double-check involves two nurses separately verifying the
prescription, calculations, and product. This process reduces the likelihood of human error
reaching the patient. Barcode scanning is a helpful tool but should supplement, not replace,
nursing judgment. Ensuring multiple layers of safety is the hallmark of high-quality patient
care in acute settings.
7. A multidisciplinary team is conducting a Root Cause Analysis (RCA) after a sentinel event.
What is the primary purpose of this process?
A. To identify underlying system failures and prevent future occurrences.
B. To determine the legal liability of the hospital in a lawsuit.
C. To identify which staff member is most responsible for the incident.
D. To provide a report to the insurance company for reimbursement.
Correct Answer: A
Rationale: Root Cause Analysis is a structured method used to look beyond the surface of
an event. It aims to find the latent factors and system vulnerabilities that allowed an error
to happen. The goal is never to assign blame to an individual but to improve safety for all
future patients. By addressing the root cause, the facility can implement changes that make
it harder for the same mistake to recur. Continuous quality improvement depends on the
findings generated from a thorough RCA.
8. A nurse is caring for an older adult client who is at high risk for falls. Which of the following
nursing interventions is the priority?
A. Keep all four side rails up at all times to prevent the client from getting out of bed.
B. Encourage the family to stay with the client around the clock.
C. Place the client’s bed in the lowest position and lock the wheels.
D. Administer a mild sedative to keep the client calm during the night.
