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NUR 2989 CAPSTONE PROCTORED MODULE 7 ATI CAPSTONE QUIZ
WITH ACTUAL QUESTIONS AND VERIFIED SOLUTIONS/A+ GRADE
“A nurse is observing client care provided by assistive personnel (AP). Which of the following actions should prompt the charge nurse to intervene? a. The AP puts on clean gloves prior to brushing a client's teeth. b. The AP attaches a client's urinary drainage bag to the bed frame. c. The AP instructs a client who needs assistance with turning to place his arms at his side before the turn.
d. The AP applies moisturizing cream to the feet of a client who has diabetes mellitus. -
CORRECT ANSWER c. The AP instructs a client who needs assistance with turning to place
his arms at his side before the turn." "A nurse is caring for an adolescent client who has a new diagnosis of schizophrenia. The client's parents are tearful and express feelings of guilt. Which of the following statements should the nurse make? a. "You said that you feel guilty about your daughter's diagnosis. Lets talk about what is causing you to feel this way". b. "Your provider has explained the causes of schizophrenia why you feel guilty about your daughter diagnosis?" c. "You should not feel guilty about your daughter's diagnosis. Schizophrenia is unpreventable". d. "I'm sure your daughter's diagnosis is very difficult to deal with, but everything will be all
right once she receives the proper treatment". - CORRECT ANSWER a. "You said that you feel
guilty about your daughter's diagnosis. Lets talk about what is causing you to feel this way"." "A nurse in the emergency department is assessing a client who has experienced intimate partner abuse. The nurse should monitor the client for which of the following behavioral findings? a. Body image disturbance b. Altered role performance c. Personal identity disturbance
d. Self- esteem disturbance - CORRECT ANSWER d. Self- esteem disturbance"
"A nurse is caring for a client who is confused and has pulled out her peripheral IV catheter three times. Which of the following actions should the nurse consider? a. Move the client close to the nurses' station b. Administer a mild sedative to the client
c. Place mitten restraints on the clients' hands d. Reorient the client to time, place, and person -
CORRECT ANSWER c. Place mitten restraints on the clients' hands"
"A nurse is planning care for a newly admitted client who has major depressive disorder following the loss of a child. Which of the following goals should the nurse identify as the priority? a. The client assumes an active role in her care planning process b. The client makes a contract not to harm herself c. The client identifies positive qualities about herself.
d. The client exhibits expected grieving behaviors - CORRECT ANSWER b. The client makes a
contract not to harm herself" "A nurse manager is reviewing the Good Samaritan laws with a group of newly licensed nurses. Which of the following statements by the nurse manager is appropriate? a. "Good Samaritan laws prohibit the victim from filing lawsuit against the nurse". b. "If you render aid in an accident, do not leave the scene until another competent person can take over" c. "Federal laws require a licensed nurse to render aid in an emergency"
d. "A nurse who volunteers at a summer camp for children is covered by Good Samaritan laws". -
CORRECT ANSWER b. "If you render aid in an accident, do not leave the scene until another
competent person can take over"" "A nurse is interviewing a female client who is Hispanic. The client's answers the questions and states. "she speaks only a little English." Which of the following actions should the nurse take? a. Ask the client's partner to translate questions and answer for the client b. Arrange to complete the assessment with only the client and a translator's present c. Use an internet website ending in.com to translate for the client
d. Ask a male student nurse to translate for the client - CORRECT ANSWER b. Arrange to
complete the assessment with only the client and a translator's present" "A nurse is caring for an older adult client who has a fractured hip and will require rehabilitative care. The client's family asks the nurse for information about this type of care. Which of the following explanations should the nurse provide? a. Services are centered in long-term care facilities b. This service focuses on teaching the primary caregivers to meet the client's needs c. The emphasis is on the client's complete recovery from the illness or injury
d. This service began with the client's admission to the hospital - CORRECT ANSWER c. The
emphasis is on the client's complete recovery from the illness or injury" "A nurse is planning care for 4-year-old child who requires airborne precautions. Which of the following activities should the nurse plan for child? a.Constructing a model airplane
b. "Our car seat is an infant model and is anchored in the car" c. "I can fit my hand between the baby and the car seat harness"
d. "Our car seat is front-facing in the back seat" - CORRECT ANSWER b. "Our car seat is an
infant model and is anchored in the car"" "A charge nurse allows two nurses who are arguing about who gets to go to lunch first to go together. The charge nurse agrees to take care of both of the nurses' client while lunch. The charge nurse is demonstrating which of the following types of conflict management? a. Avoiding b. Cooperating c. Compromising
d. Competing - CORRECT ANSWER b. Cooperating"
"A nurse is observing a newly licensed nurse prepare a sterile field. For which of the following actions should the nurse intervene? a. Holds gauze package 15cm (6in) above the sterile field. b. Holds a bottle of solution with the label away from the palm of the hand c. Wears sterile gloves when moving when moving sterile items on the sterile field
d. Position the wrapped package on the bedside table so the outer flap is away from her. -
CORRECT ANSWER b. Holds a bottle of solution with the label away from the palm of the
hand" "A nurse needs to lift a box in a supply room .Which of the following actions should the nurse take to prevent an injury due to lifting? a. Bend at the waist to pick up the box b. Stand with his feet close together while lifting c. Keep the box close to his body as he lifts
d. Twist when placing the box to his side - CORRECT ANSWER c. Keep the box close to his
body as he lifts" "A nurse is planning care at the beginning of a shift. Which of the following tasks could a nurse assign to assistive personnel (AP)? a. Providing a client's postmortem care b. Inserting indwelling urinary catheter c. Assisting the client to select a low-residue diet
d. Removing a client's nasogastric tube - CORRECT ANSWER a. Providing a client's
postmortem care" "A charge nurse is teaching a new nurse how to initiate IV access on a client. Which of the following actions by the new nurse indicates an understanding of the teaching?
a. Washes hands with soap and water before the procedure b. Shaves the selected insertion site with a razor prior to the procedure c. Applies the tourniquet 1 inch above the selected insertion site
d. Applies sterile gloves prior to inserting the IV catheter - CORRECT ANSWER a. Washes
hands with soap and water before the procedure" "A nurse observing assistive personnel (AP) changing the linens on the bed of a client who is immobile. Which of the following action by the AP should the nurse identify as an indication of the need to intervene? a. Lowers the side rail on the side of the bed closest to the AP b. Reaches over the bed to straighten the fitted sheet c. Rolls the client to one side of the bed
d. Raises the bed to waist level - CORRECT ANSWER b. Reaches over the bed to straighten the
fitted sheet" "A nurse is teaching a community education course about the physical complication related to substance use disorder. Which of the following findings should the nurse include in the discussion as a health risk of heroin use? a. Nasal septum perforation b. Permanent short-term memory loss c. Slowed breathing
d. Acute pancreatitis - CORRECT ANSWER c. Slowed breathing"
"Assistive personnel (AP) contact a nurse manager and reports that on the last shift a nurse seemed distracted and that a client reported that the nurse smelled of alcohol. The AP alleges that nurses were drinking alcohol during the shift. Which of the following actions should the nurse manager take first? a. Confront them b. Develop a disciplinary plan for the nurse c. Perform an investigation into the facts surrounding the incident
d. Refer the nurse to the state board of nursing diversion program - CORRECT ANSWER c.
Perform an investigation into the facts surrounding the incident" "56. A nurse is assisting with the admission of a child who has measles. Which of the following isolation precaution should the nurse initiate? a. Droplet b. Airborne c. Contact
"A nurse is planning for a client who has become increasingly anxious and confused. Which of the following actions should the nurse include to avoid the use of physical restraints? (select all that apply) a. Attend to the client's needs for toileting b. Elevate all side rails on the bed. c. Ensure effective pain management d. Orient client frequently to the environment
e. Assign the client to a room near the nurse station - CORRECT ANSWER a. Attend to the
client's needs for toileting c. Ensure effective pain management d. Orient client frequently to the environment e. Assign the client to a room near the nurse station" "A nurse is caring for a client who experienced an infection site of intravenous catheter. Which of the following findings should the nurse expect? a. Purulent drainage is noted from the site b. The client reports numbness at the site c. Skin over the site is sloughing
d. The vein appears cordlike - CORRECT ANSWER a. Purulent drainage is noted from the
site" "A nurse is caring for a 48-year-old client who is grieving following the death of her husband seven months ago. The client reports that she has lost 30lb and is having difficulty sleeping. Which of the following factors indicate the client is experiencing maladaptive grieving? a. The client is 48 years old b. The client is having difficulty sleeping c. The client has lost 30lb
d. The client's husband died seven months ago - CORRECT ANSWER c. The client has lost
30lb" "A nurse is caring for an older adult client who has a terminal illness and is ventilator- dependent. The client is alert and oriented and he wants to discontinue use of the ventilator. The nurse should be aware that continued treatment against the client's wishes is a violation of which of the following ethical principles? a. Fidelity b. Autonomy c. Justice
d. Veracity - CORRECT ANSWER d. Veracity"
"A nurse is teaching a community education course about the physical complications related to substance use disorder. Which of the following findings should the nurse identify as the primary cause of liver cirrhosis? a. Cocaine b. Caffeine c. Alcohol
d. Inhalant's - CORRECT ANSWER c. Alcohol"
"A nurse is caring for a client following a recent suicide attempt. Which of the following actions should the nurse take? a. Inspect the client's personal belongings b. Place metal utensils on the client's meal tray c. Tuck bedcovers over client's hands and arms
d. Assign the client to a private room. - CORRECT ANSWER a. Inspect the client's personal
belongings" "A nurse is teaching a newly licensed nurse about transcribing prescriptions. Which of the following examples should the nurse include in the instructions? a. Desmopressin .1mL intranasal qd b. Metformin 500mg 1 tablet po daily c. Losartan 50.0mg POQD
d. Zolpidem,5mg PD,HS - CORRECT ANSWER d. Zolpidem,5mg PD,HS"
"A nurse is providing discharge teaching to a client who had a total hip arthroplasty. Which of the following information should the nurse include in the teaching? a. Use a twisting motion when turning to pick an object up b. Bend at waist to put shoes on when sitting c. Sit with legs apart at the ankles
d. Cleanse the incision with hydrogen peroxide - CORRECT ANSWER c. Sit with legs apart at
the ankles" "A nurse is caring for a client who is scheduled for surgery. The nurse's role in regard to informed consent is which of the following? a. Determine the client's level of understanding about the procedure b. Ensuring the charge nurse is available to witness the client's signature on the consent form c. Discussing alternative treatment options
"A nurse is applying wrist restraints to a client who is confused and attempting to pull out a chest tube. Which of the following actions should the nurse taking when using restraints? a. Ensue that 1 finger breath of space is between the client's wrists and the restraint b. Remove the restraint to check integrity of the skin every 4hr c. Tie the restraint using a quick release knot
d. Secure the restraints to the side rails. - CORRECT ANSWER c. Tie the restraint using a
quick release knot" "A nurse teaching about safety recommendations for car seats with the parents of a 24- month- old toddler who is in the 50th percentile for height and weight. Which of the following instructions should the nurse include in the teaching? a. Position a convertible seat forward facing in the front passenger side and inactive the airbag b. Position the toddler rear-facing in the middle of the back seat c. Position a booster sat forward facing in the middle of the back seat
d. Position a convertible seat rear facing in the front passenger side - CORRECT ANSWER b.
Position the toddler rear-facing in the middle of the back seat" "A nurse is assessing four clients for indications of general adaptation syndrome (GAS). Which of the following clients should the nurse monitor closely for GAS? a. A 22year old client who has type 1 diabetes mellitus b. A 59year old client who has stage II Alzheimer's disease c. A 68-year-old client who has viral pneumonia
d. A 40-year-old client who has ulcerative colitis - CORRECT ANSWER d. A 40-year-old client
who has ulcerative colitis" "A nurse is caring for a client who is experiencing dysphagia. The nurse should recommend a referral to which of the following members of the health care team? a. Speech therapist b. Social worker c. Respiratory therapist
d. Occupational therapist - CORRECT ANSWER a. Speech therapist"
"An older adult is scheduled to have an elective surgical procedure and informs the nurse that she wants to be designated as a "do not resuscitate" (DNR) case. Which of the following responses should the nurse provide? a. " You provider needs to talk with you concerning your request" b. "You need to let you provide know your wishes after the procedure" c. "You need to discuss your request with the hospital chaplain"
d. "This is a minor procedure, there is no need for this request" - CORRECT ANSWER a. " You
provider needs to talk with you concerning your request"" "A nurse is assessing an adolescent client who has attention deficit hyperactivity disorder (ADHD). Which of the following findings should the nurse expect? a. Elevated mood b. Anxiety c. Emotional numbing
d. Impulsivity - CORRECT ANSWER d. Impulsivity"
"A nurse is developing the plan of care for a client who does not speak the same language as the nurse. Which of the following interventions should the nurse include? a. Make sure a family member is present to interpret for the staff b. Encourage the client to nod to indicates understanding c. Determine the client's level of fluency in his primary language
d. Speak directly to the interpreter when teaching the client - CORRECT ANSWER b.
Encourage the client to nod to indicates understanding" "A nurse has completed care procedures for client who requires airborne precautions. Which of the following items of personal protective equipment (PPE) should the nurse remove last? a. Gloves b. Gown c. Mask
d. Goggles - CORRECT ANSWER c. Mask"
"Following a tornado, a nurse is determining which of the clients assigned to her care can be discharged to free up beds for injured clients. Which of the following clients should the nurse recommend for discharge? a. An older adult who was admitted for diabetic ketoacidosis and his most recent ABGs show his pH is now 7. b. Middle adult who is 36hr postoperative from an open laminectomy c. An adolescent client who was admitted 24hr ago due to a spontaneous pneumothorax
d. A young adult client who has Crohn's disease and is 1 day preoperative for an ileostomy -
CORRECT ANSWER d. A young adult client who has Crohn's disease and is 1 day preoperative
for an ileostomy" "A community mental health nurse is assessing client who has schizophrenia. Which of the following findings indicates the client might be relapsing? a. The client reports feelings of anger toward her provider b. The client states have started smoking again c. The client is wearing mismatched clothing
"A nurse is teaching a class on torts. The nurse should instruct the class that administering an antibiotic medication to a competent client after the client has refused it is an example of which of the following torts? a. Negligence b. Assault c. Battery
d. False imprisonment - CORRECT ANSWER c. Battery"
"A nurse overhears two assistive personnel (AP) from the medical-surgical unit discussing a hospitalized client while in the cafeteria. Which of the following is the priority nursing action? a. Document the occurrence in a personal log b. Complete an incident report c. Quietly tell the APs that this is not appropriate d. Ask the nurse manager to provide an in-service program about confidentiality to the staff on the
unit. - CORRECT ANSWER c. Quietly tell the APs that this is not appropriate"
"A nurse is admitting a client who requires droplet precautions due to influenza. Which of the following actions should the nurse take? a. Wear a mask when providing care to the client b. Ensure the client's room has HEPA filtration c. Place the client in a room with negative airflow
d. Wear a gown when providing care to the client - CORRECT ANSWER a. Wear a mask when
providing care to the client" "A nurse sees assistive personnel (AP) entering the room of a client who requires transmission- based precautions without using the appropriate personal protective equipment (PPE). Which of the following actions should the nurse take first? a. Notify the charge nurse about the AP's need for training b. Provide the appropriate PPE to the AP c. Speak with AP when he exits the room about the appropriate protocol
d. Volunteer to provide an in-service about infection control - CORRECT ANSWER c. Speak
with AP when he exits the room about the appropriate protocol" "A charge nurse is reviewing guidelines for initiating airborne precautions. Which of the following clients should the nurse identify as requiring airborne precautions? a. A client who has measles b. A client who has pertussis c. A client who has streptococcal pharyngitis
d. A client who has scabies - CORRECT ANSWER a. A client who has measles"
"A nurse on a medical surgical unit is planning to delegate tasks to an adult volunteer. Which of the following task should the charge nurse avoid assignment to the volunteer? a. Observing a postoperative client who is confused b. Assisting a client who has difficult seeing the foods on the tray while eating c. Delivering a routine urine specimen to the laboratory
d. Delivering meal trays to clients in their rooms - CORRECT ANSWER a. Observing a
postoperative client who is confused" "A nurse on a medical surgical unit is assigning task to assistive personnel (AP). Which of the following task should the nurse delegate to the AP? (select all that apply) a. Irrigate a wound b. Transfer a client to a stretcher c. Demonstrate the technique to instill eye drops d. Ambulate client who has a cane
e. Record urinary output - CORRECT ANSWER b. Transfer a client to a stretcher
d. Ambulate client who has a cane e. Record urinary output" "A nurse is assessing the medical record of a female client who has anorexia nervosa. Which of the following findings should the nurse expect? a. Heat intolerance b. Low bone density c. Heavy monthly period
d. Decreased cholesterol levels - CORRECT ANSWER b. Low bone density"
"A nurse is teaching a community education course about the physical complications related to substance use disorder. Which of the following findings should the nurse include in the discussion as a health risk of heroin use? a. Nasal septum perforation b. Permanent short-term memory loss c. Slowed breathing
d. Acute pancreatitis - CORRECT ANSWER c. Slowed breathing"
"A nurse is caring for a client who has dementia. The client is agitated and is have difficulty staying in his chair. Which of the following actions should the nurse take first? a. Place a seat alarm in the client's chair b. Place the client in bed with the two side rails raised c. Apply a vest restraint on the client
d. Administer lorazepam the client - CORRECT ANSWER a. Place a seat alarm in the client's
chair" "A nurse is assessing a client's ability to ambulate with crutches using a three-point gait. Which of the following actions should the nurse identify as a risk to the client's safety
"A nurse in an emergency department is caring for a client who is experiencing acute alcohol withdrawal. Which of the following actions should the nurse take first? a. Obtain a blood specimen b. Insert an IV access site c. Implement seizure precautions
d. Perform a neurological exam - CORRECT ANSWER c. Implement seizure precautions"
"A nurse is caring for a client who has schizophrenia and is having difficulty with performing ADLs. The nurse should consult with which of the following members of the interdisciplinary team to assist the client? a. Recreational therapist b. Occupational therapist c. Psychiatric social worker
d. Psychiatric clinical nurse specialist - CORRECT ANSWER b. Occupational therapist"
"A nurse is giving change-of-shift report using SBAR to the oncoming nurse on a client who has a traumatic brain injury. Which of the following information should the nurse include in the background segment of SBAR? a. Plan of care changes for upcoming shift b. Glasgow results c. Intracranial pressure readings
d. Code status - CORRECT ANSWER d. Code status"
"A nurse is teaching a group of clients about first aid care for a bee sting. Which of the following information should the nurse include in the teaching? a. Remove the stinger by scraping it off with a knife blade b. Suck the wound c. Apply a tourniquet
d. Apply a warm pack - CORRECT ANSWER a. Remove the stinger by scraping it off with a
knife blade" "A nurse is providing home safety information for an older client who uses a cane. Which of the following statements should the nurse include in the teaching? a. "You should advance your weak leg forward to the cane, then move your stronger leg" b. "You should hold the cane in your weak hand when ambulating" c. "The cane's height should be the same as the distance from the floor to the crest of your hip bone"
d. "you should advance the cane 12 to 14 inches before taking a step" - CORRECT ANSWER a.
"You should advance your weak leg forward to the cane, then move your stronger leg""
"A nurse is caring for a client who has a new diagnosis of human immunodeficiency virus(HIV) He states, I don't care what the doctors say, there is no way I can have HIV and I don't need treatment for something I don't have. The nurse identifies the client is experiencing which of the following types of crisis? a. Maturational b. Situational c. Adventitious
d. Internal - CORRECT ANSWER b. Situational"
"A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action by the nurse? a. Rephrase statements the client does not hear b. Speak using his usual tone of voice c. Determine if the client uses hearing aids
d. Stand directly in front of the client. - CORRECT ANSWER c. Determine if the client uses
hearing aids" "A nurse is providing discharge teaching to a client who was recently diagnosed with a latex allergy. Which of the following client statement indicates an understanding of the teaching? a. "I will use dishwashing gloves when cleaning the dishes " b. "I will buy balloons for my son's birthday" c. "I will apply elastic bandages to cuts"
d. " I will use ink pens for writing" - CORRECT ANSWER d. " I will use ink pens for writing""
"A nurse is planning care for a client who has generalized anxiety disorder. Which of the following intervention should the nurse implement to promote relaxation? a. Help the client to identity his previous accomplishments b. Encourage the client to identity his positive qualities c. Assist the client in practicing meditation
d. Recognize the client's spiritual preferences. - CORRECT ANSWER c. Assist the client in
practicing meditation" "A nurse is reviewing a provider's prescriptions for four clients. Which of the following prescriptions is outside the legal scope of practice for the nurse? a. Complete a Glasgow coma scale on a client b. Insert a tunneled central venous catheter of a client c. Perform a type and cross match on a client for 2 units of packed RBCs
d. Provide initial education for a client who has type 1 diabetes mellitus - CORRECT ANSWER
b. Insert a tunneled central venous catheter of a client"
a. Ability to bathe himself b. Ability to dress himself c. Ability to perform oral hygiene d. Ability to identify how often he should schedule his car for an oil change
e. Ability to balance his bank account - CORRECT ANSWER a. Ability to bathe himself
b. Ability to dress himself c. Ability to perform oral hygiene" "A nurse is planning care for a client who is to undergo a stem cell transplant. Which of the follow actions should the nurse plan to take? a. Provide the client with 1,000 ML of water of drink to drink every 12hr. b. Keep blood pressure equipment in the client's room c. Place the client in a negative airflow room
d. Monitor the client's vital signs once every 8hr. - CORRECT ANSWER b. Keep blood
pressure equipment in the client's room" "A nurse is reviewing information about the Health Insurance Portability and accountability Act (HIPAA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching? a. "A client's address would be an example of personally identifiable information". b. "Information about a client can be disclosed to family members at any time". c. "HIPAA established regulations of individually identifiable health information in verbal, electronic or written form"
d. "HIPAA is a federal law, not a state law" - CORRECT ANSWER b. "Information about a
client can be disclosed to family members at any time"."
