Rasmussen University Associate Degree in Nursing Capstone Benchmark 1

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Sample questions from Rasmussen University Associate Degree in Nursing Capstone Benchmark 1

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

1. 1.A nurse is caring for a client with pneumonia who suddenly becomes restless and has an oxygen saturation of 86% on room air. Which action should the nurse take first?

   • A.Apply supplemental oxygen and reassess the client's response
   • B.Obtain a sputum specimen for culture
   • C.Encourage the client to increase oral fluids
   • D.Notify the health care provider after documenting the findings

   Rationale: The low oxygen saturation and new restlessness suggest impaired oxygenation, so oxygen support is the immediate priority. A sputum culture and fluids may support treatment but do not correct hypoxemia; documenting and notifying the provider should not delay immediate intervention. Reassess oxygenation and escalate care if the client does not improve.

2. 2.A client with heart failure reports sudden severe dyspnea and is coughing pink, frothy sputum. Which action should the nurse take first?

   • A.Place the client in high-Fowler position and apply oxygen
   • B.Obtain a daily weight
   • C.Encourage the client to drink water
   • D.Prepare the client for discharge teaching

   Rationale: The findings indicate acute pulmonary edema, requiring immediate support of breathing and oxygenation. A daily weight is useful for ongoing heart-failure monitoring, but it is not the priority during respiratory distress; fluids can worsen congestion, and discharge teaching is inappropriate during an emergency. Notify the provider or rapid response team while continuing to assess respiratory status.

3. 3.A client with diabetes is awake, diaphoretic, and shaky; the blood glucose is 54 mg/dL. Which action should the nurse take?

   • A.Give 15 g of a rapid-acting oral carbohydrate
   • B.Administer the scheduled rapid-acting insulin
   • C.Give a high-fat snack and recheck in 1 hour
   • D.Withhold all food until the provider is notified

   Rationale: An alert client with hypoglycemia should receive about 15 g of rapid-acting carbohydrate, followed by a glucose recheck in about 15 minutes. Insulin would worsen the hypoglycemia, and a high-fat snack delays glucose absorption; withholding food leaves the low glucose untreated. If the client cannot safely swallow, use the prescribed glucagon or intravenous dextrose protocol.

4. 4.A client with chronic obstructive pulmonary disease is receiving oxygen at 2 L/min by nasal cannula. The client becomes increasingly somnolent. What should the nurse do first?

   • A.Assess respiratory status and oxygenation, then notify the provider of the change
   • B.Remove the oxygen immediately
   • C.Encourage the client to sleep
   • D.Increase oxygen to 10 L/min without reassessment

   Answer and rationale are in the full material.

5. 5.A client with suspected stroke arrives at the emergency department. Which assessment finding should the nurse report immediately because it affects eligibility for time-sensitive treatment?

   • A.The exact time the client was last known well
   • B.The client's usual bedtime
   • C.The client's preferred pharmacy
   • D.The date of the last influenza vaccination

   Answer and rationale are in the full material.