Nr 452 Capstone

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Sample questions from Nr 452 Capstone

This material has 90 questions with answers and rationales. Here are the first 5.

1. 1.In the emergency department, a client with suspected stroke has sudden right-sided weakness and slurred speech. Which action is the priority?

   • A.Give aspirin as prescribed
   • B.Determine the time the client was last known well
   • C.Offer water to assess swallowing
   • D.Lower the head of the bed and elevate the legs

   Rationale: The time the client was last known well determines eligibility for time-sensitive stroke interventions. Aspirin is not given until hemorrhage is excluded, and oral intake is unsafe until swallowing is assessed. Elevating the legs does not address the immediate need to activate stroke care.

2. 2.A client with heart failure is preparing for discharge. Which instructions should the nurse include? Select all that apply.

   • A.Report a gain of 2 lb (0.9 kg) in 24 hours
   • B.Weigh yourself each morning after urinating
   • C.Take an extra dose of potassium whenever you feel weak
   • D.Stop taking the diuretic when your breathing improves
   • E.Limit sodium as directed by your health care provider

   Rationale: Daily weights under consistent conditions can reveal fluid retention, and a rapid gain of 2 lb in a day should be reported. Sodium restriction as prescribed helps reduce fluid overload. Stopping a diuretic or taking extra potassium without direction can cause serious complications.

3. 3.Which assessment finding in a client with a lower-leg cast requires immediate follow-up?

   • A.A small amount of swelling during the first day
   • B.Warm toes with brisk capillary refill
   • C.Mild itching beneath the cast
   • D.Increasing pain unrelieved by prescribed analgesia

   Rationale: Increasing pain that is not relieved by analgesia can indicate compartment syndrome and requires immediate assessment. Mild itching and limited early swelling can occur, while warm toes and brisk refill are reassuring perfusion findings. The nurse should not insert objects under the cast to relieve itching.

4. 4.A client receiving chemotherapy has an absolute neutrophil count of 400/mm3. Which actions are appropriate? Select all that apply.

   • A.Perform hand hygiene before each contact
   • B.Allow visitors with mild respiratory symptoms if they wear a mask
   • C.Serve raw eggs to increase protein intake
   • D.Monitor temperature and report a fever promptly
   • E.Avoid fresh flowers in the room

   Answer and rationale are in the full material.

5. 5.Which finding is most consistent with hypoglycemia in a client with diabetes?

   • A.Shakiness, sweating, and difficulty concentrating
   • B.Polyuria and fruity breath
   • C.Gradual onset of blurred vision over several weeks
   • D.Warm, dry skin and deep respirations

   Answer and rationale are in the full material.