Answer Key
AM RN Captsone Summer 2024
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University:
The University of Texas at Tyler -
Course:
NURS 4339 | Capstone Course Academic year:
2024
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Views:
315
Pages:
51
Author:
Mary Drammeh
Detailed Answer Key
AM RN CAPSTONE EXAM SUMMER 24
1. Complete the diagram by dragging from the choices below to specify what condition the client is most likely
experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor
to assess the client's progress.
Answers cannot be displayed for this alternate item format.
Rationale: The nurse should take action by apply O2 at 2 L/min via nasal cannula and elevate the head of the
client's bed because the client’s condition is worsening related to their congestive heart failure .The
nurse should continue to monitor the parameters of the client’s respiratory rate and oxygen
saturation to assess the client’s progress. The client’s respirations have increased in rate and are
more labored. The client’s oxygen saturation level has decreased and their lung sounds have
deteriorated from a few fine crackles in bilateral bases to coarse crackles throughout.
2. Complete the diagram by dragging from the choices below to specify what condition the client is most likely
experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor
to assess the client's progress.
Answers cannot be displayed for this alternate item format.
Rationale: The nurse should teach the client signs of hyperglycemia and assess their feet for sensation
because the client is most likely experience type 1 diabetes mellitus because the HgA1c is elevated
to a level indicating only fair diabetic control and the fingerstick blood glucose level is high, which is
indicative of diabetes. The nurse will need to assess for the potential diabetic complication of
peripheral neuropathy in the feet. The nurse should monitor urinary output and fingerstick blood
glucose. This will allow the nurse to determine whether the medication and diet are effective in
controlling the client’s glucose levels.
3. Complete the diagram by dragging from the choices below to specify what condition the client is most likely
experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor
to assess the client’s progress.
Answers cannot be displayed for this alternate item format.
Rationale: The nurse should obtain an electrocardiogram because the client has hypokalemia and an irregular
apical heart rate. The nurse should implement fluid replacement because the client has
manifestations of dehydration due to diarrhea. The nurse should monitor the client’s urine output
and potassium level to assess the client's progress.
4. Complete the diagram by dragging from the choices below to specify what condition the client is most likely
experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor
to assess the client's progress.
Answers cannot be displayed for this alternate item format.
Rationale: The nurse should administer a bronchodilator and prepare the client for intubation because the
client is likely experiencing respiratory acidosis and respiratory distress. The nurse should then
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monitor for the correct placement of the ETT following intubation as well as the client's arterial blood
gases to normalize.
5. Complete the diagram by dragging from the choices below to specify what condition the client is most likely
experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor
to assess the client’s progress.
Answers cannot be displayed for this alternate item format.
Rationale: The nurse should obtain a stool specimen to check for Heliobacter pylori and request a proton
pump inhibitor because the client is most likely experiencing peptic ulcer disease (PUD). The client
is manifesting dyspepsia, which is the most common manifestation associated with PUD. The client
describes their pain as a sharp, burning pain that occurred 1 hr after eating. Risk factors for PUD
include obesity, cigarette smoking, and ingestion of NSAIDs and alcohol. The nurse should monitor
orthostatic blood pressure and hemoglobin and hematocrit because complications of PUD include
upper GI bleeding and hypovolemia. The client's hemoglobin and hematocrit should be monitored
for changes from the baseline. Fluid volume deficit can occur from an ulcer that is bleeding.
Orthostatic hypotension and dizziness are signs of fluid volume deficits.
6. The nurse is reviewing the client's assessment to prepare the client's plan of care. Complete the diagram by
dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse
should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Answers cannot be displayed for this alternate item format.
7. Complete the diagram by dragging from the choices below to specify what condition the client is most likely
experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor
to assess the client's progress.
Answers cannot be displayed for this alternate item format.
8. Complete the diagram by dragging from the choices below to specify what condition the client is most likely
experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor
to assess the client's progress.
Answers cannot be displayed for this alternate item format.
Rationale: Upon recognizing and analyzing the cues of fever, nuchal rigidity, seizure, and abnormal CSF
results, the nurse’s priority hypotheses is that this client is most likely experiencing bacterial
meningitis. It is important to generate solutions and take actions that will prevent injury and protect
the client if there is further seizure activity. The nurse should ensure oxygen equipment is available
in the client’s room if another seizure occurs. With the CSF culture revealing N. meningitides, the
client will need to be placed on droplet precautions. To evaluate these interventions the nurse
should monitor the client’s level of consciousness and WBC count.
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9. For each potential provider's prescription at 4 weeks, click to specify if the prescription is anticipated, nonessential,
or contraindicated for the client.
Answers cannot be displayed for this alternate item format.
Rationale: Place the client in a private room is anticipated. The client has a decreased WBC count and
should be placed in a private room to reduce the risk of infection. Insert an indwelling urinary
catheter is contraindicated. The client is voiding independently. An indwelling urinary catheter
places the client, who has a decreased WBC count, at risk for a catheter-associated urinary tract
infection. Place the client on droplet precautions is nonessential. The client has a decreased
WBC count and should be placed in a private room to reduce the risk of infection. The client does
not have an infection that requires droplet precautions. Check the client’s rectal temperature
once daily is contraindicated. The client’s platelet count and WBC levels are less than the
expected reference range, placing the client at risk for bleeding and infection. A rectal temperature
can cause rectal trauma that can result in bleeding or infection. Rinse the client’s mouth with
0.9% sodium chloride every 4 hr is anticipated. Mouth pain is a manifestation of mucositis. The
nurse should provide the client with frequent mouth rinses to provide comfort and promote healing.
10. The nurse is planning care for the client. For each potential prescription, indicate whether it is indicated,
nonessential, or contraindicated.Select one or more in each option.
Answers cannot be displayed for this alternate item format.
Rationale: Apply continuous ECG monitoring is anticipated. The nurse should anticipate a prescription to
apply continuous ECG monitoring to monitor for arrhythmia changes.Obtain the client's family
history is non-essential. Obtaining the client's family history is not essential at this time. It will not
change the treatment plan, and the client needs to be treated immediately.Administer O2 to
maintain oxygen saturation greater than 90% is anticipated. The nurse should anticipate a
prescription for supplemental oxygen if needed.Administer furosemide IV is contraindicated.
Administering furosemide to the client is contraindicated at this timePreparing the client for
intubation is contraindicated. There is no indication at this time that the client needs to be
intubatedObtain vascular access is anticipated. The nurse should anticipate obtaining vascular
access.
11. A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The
nurse should monitor the client for which of the following complications? (Select all that apply.)
Answers cannot be displayed for this alternate item format.
Rationale: Hypotension is correct. Lack of sympathetic input can cause a decrease in blood pressure. The
nurse should maintain the client's SBP at 90 mm Hg or above to adequately perfuse the spinal
cord.
Polyuria is incorrect. The nurse should check the client for bladder distention and inability to
urinate due to ineffective function of the bladder muscles.
Hyperthermia is incorrect. The nurse should monitor the client for hypothermia caused by a lack
of lack of sympathetic input.
Absence of bowel sounds is correct. Spinal shock leads to decreased peristalsis, which could
cause the client to develop a paralytic ileus.
Weakened gag reflex is correct. The nurse should monitor the client for difficulty swallowing, or
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coughing and drooling noted with oral intake.
12. A nurse is admitting a client who has acute pancreatitis. Which of the following provider prescriptions should the
nurse anticipate?
A. Initiate a low-residue diet.
Rationale: One of the manifestations of acute pancreatitis is abdominal pain. The nurse should anticipate
the provider will prescribe withholding of foods and fluids. This serves to manage the client's
pain by limiting gastrointestinal activity and stimulation of the pancreas.
B. Pantoprazole 80 mg IV bolus twice daily
Rationale: The nurse should anticipate a provider's prescription for a proton pump inhibitor to decrease
gastric acid production, which ultimately decrease pancreatic secretions.
C. Ambulate twice daily.
Rationale: The nurse should anticipate a provider prescription for bed rest during the acute stage of
pancreatitis. Bed rest decreases the metabolic rate and the secretion of pancreatic enzymes.
D. Pancrelipase 500 units/kg PO three times daily with meals
Rationale: The nurse should identify that pancrelipase, an enzyme replacement medication, is used in the
treatment of clients who have chronic pancreatitis. It is not used in the treatment of acute
pancreatitis.
13. A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the
following room assignments should the nurse make for the client?
A. A room with air exhaust directly to the outdoor environment
Rationale: A room with air exhaust directly to the outside environment eliminates contamination of other
client-care areas. This type of ventilation system is referred to as an airborne infection isolation
room.
B. A room with another nonsurgical client
Rationale: A two-bed room with another nonsurgical client exposes the other client to tuberculosis. A client
who has tuberculosis should have a private room.
C. A room in the ICU
Rationale: A client who has active tuberculosis and no other comorbidities is not critically ill.
D. A room that is within view of the nurses' station
Rationale: The client's room should be well ventilated and private, but it is not necessary for it to be close
to the nurses' station.
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14. A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a
motor-vehicle crash. Identify the sequence of actions the nurse should take. (Move the actions into the box on the
right, placing them in the selected order of performance. Use all the steps.)
C. Open the airway using a jaw-thrust maneuver.
D. Determine effectiveness of ventilator efforts.
B. Establish IV access.
A. Perform a Glasgow Coma Scale assessment.
E. Remove clothing for a thorough assessment.
15. A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the
following sets of values should the nurse expect?
A. pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg
Rationale: The nurse should expect a client who has renal failure to have metabolic acidosis, which is
characterized by a low HCO3-, a low pH, and a low or normal PaCO2. Expected reference
ranges for these laboratory values are as follows: pH 7.35 to 7.45, HCO3- 21 to 28 mEq/L, and
PaCO2 35 to 45 mm Hg.
B. pH 7.30, HCO3- 26 mEq/L, PaCO2 50 mm Hg
Rationale: These values indicate respiratory acidosis, which is associated with respiratory disorders, such
as pulmonary edema and pneumonia.
C. pH 7.50, HCO3- 20 mEq/L, PaCO2 32 mm Hg
Rationale: These values indicate respiratory alkalosis, which is associated with hyperventilation.
D. pH 7.55, HCO3- 30 mEq/L, PaCO2 31 mm Hg
Rationale: These values indicate metabolic alkalosis, which is associated with severe emesis or gastric
suctioning.
16. A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority?
A. Positive Western blot test
Rationale: The client is already identified as HIV positive. Therefore, another value is the priority.
B. CD4-T-cell count 180 cells/mm3
Rationale: A CD4-T-cell count of less than 180 cells/mm3 indicates that the client is severely
immunocompromised and is at high risk for infection. Therefore, this value is the priority for the
nurse to report to the provider.
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C. Platelets 150,000/mm3
Rationale: The client's platelet count is within the expected reference range. Therefore, another value is
the priority.
D. WBC 5,000/mm3
Rationale: The client's WBC count is within the expected reference range. Therefore, another value is the
priority.
17. A nurse is caring for an adolescent who has hemophilia A and is scheduled for wisdom teeth extractions. Prior to
the procedure, the nurse should anticipate that the client will receive which of the following products?
A. Recombinant
Rationale: The underlying problem of hemophilia is a deficiency of clotting factors. Therefore, clients who
have hemophilia are given recombinant to replace the deficient factor as a prophylactic
measure before an invasive procedure, surgery, or when actively bleeding.
B. Packed RBCs
Rationale: Packed RBCs cannot provide the necessary clotting agents required for a client who has
hemophilia A and is scheduled for an invasive procedure.
C. Prophylactic antibiotics
Rationale: Prophylactic antibiotics cannot provide the necessary clotting agents required for a client who
has hemophilia A and is scheduled for an invasive procedure.
D. Fresh frozen plasma
Rationale: Fresh frozen plasma cannot provide the necessary clotting agents required for a client who has
hemophilia A and is scheduled for an invasive procedure.
18. A nurse is administering a tap water enema to a client who is constipated. During the administration of the enema,
the client states he is having abdominal cramps. Which of the following actions should the nurse take to relieve the
client's discomfort?
A. Lower the height of the solution container.
Rationale: If nausea or cramping occurs, the flow of water should momentarily be slowed or stopped by
lowering the device or clamping the tubing. This allows the intestinal spasm to pass while
leaving the catheter in place. The nurse should then continue administering the enema at a
slower rate once the cramping has passed.
B. Encourage the client to bear down.
Rationale: Bearing down will cause early release of the fluid, decreasing the effectiveness of the enema.
C. Allow the client to expel some fluid before continuing.
Rationale:
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Allowing the client to expel solution too early in the procedure will decrease the effectiveness of
the enema.
D. Stop the enema and document that the client did not tolerate the procedure.
Rationale: Cramping is a normal response to an enema. There are actions the nurse can take to decrease
the cramping.
19. A nurse is completing discharge teaching with a client following arthroscopic knee surgery. Which of the following
instructions should the nurse include in the teaching?
A. Remain on bedrest for the first 24 hr.
Rationale: When the client has recovered from sedation, the client will be allowed to walk, as tolerated,
but should be instructed not to overuse or strain the joint for a few days.
B. Keep the leg in a dependent position.
Rationale: Elevating the affected area in the postoperative period (12 – 24 hr) reduces pain and swelling.
C. Apply ice to the affected area.
Rationale: Arthroscopy is a surgical procedure used to visualize, diagnose and treat problems inside a
joint. Applying ice to the affected area in the immediate postoperative period (first 24 hr)
reduces pain and swelling.
D. Begin active range of motion.
Rationale: Although the client will be allowed to walk as tolerated, joint use should be minimized for the
first few days to reduce postoperative pain and swelling.
20. A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to
assess in this client? (Select all that apply.)
Answers cannot be displayed for this alternate item format.
Rationale: Dyspnea is correct. Emphysema is a lung disease involving damage to the alveoli in which they
become weakened and collapse. Dyspnea is seen in clients with emphysema as the lungs try to
increase the amount of oxygen available to the tissues.
Bradycardia is incorrect. With emphysema, the heart rate will increase as the heart tries to
compensate for less oxygen to the tissues.
Barrel chest is correct. Clients with emphysema lose lung elasticity; the diaphragm becomes
permanently flattened by hyperinflation of the lungs; the muscles of the rib cage become rigid; and
the ribs flare outward. This produces the barrel chest typical of emphysema clients.
Clubbing of the fingers is correct. Clubbing results from chronic low arterial-oxygen levels. The
tips of the fingers enlarge and the nails become extremely curved from front to back.
Deep respirations is incorrect. Clients with emphysema lose lung elasticity and have muscle
fatigue; consequently, respirations become increasingly shallow.
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21. A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on
the client's EKG should the nurse interpret as a sign of hypokalemia?
A. Abnormally prominent U wave
Rationale: Although U waves are rare, their presence can be associated with hypokalemia, hypertension
and heart disease. For a client who has hypokalemia, the nurse should monitor the EKG strip
for a flattened T wave, prolonged PR interval, prominent U wave, or ST depression.
B. Elevated ST segment
Rationale: The nurse should identify ST depression as an indication of hypokalemia.
C. Wide QRS
Rationale: The nurse should identify a widened QRS as an indication of hyperkalemia.
D. Inverted P wave
Rationale: Inverted P waves are associated with junctional rhythms.
22. A nurse is caring for a client who is 1 day postoperative following a subtotal thyroidectomy. The client reports a
tingling sensation in the hands, the soles of the feet, and around the lips. For which of the following findings should
the nurse assess the client?
A. Chvostek's sign
Rationale: The nurse should suspect that the client has hypocalcemia, a possible complication following
subtotal thyroidectomy. Manifestations of hypocalcemia include numbness and tingling in the
hands, the soles of the feet, and around the lips, typically appearing between 24 and 48 hr after
surgery. To elicit Chvostek's sign, the nurse should tap the client's face at a point just below
and in front of the ear. A positive response would be twitching of the ipsilateral (same side only)
facial muscles, suggesting neuromuscular excitability due to hypocalcemia.
B. Babinski's sign
Rationale: Babinski's sign is a diagnostic test for brain damage or upper motor neuron damage. It is
positive if the toes flare up when the nurse strokes the plantar aspect of the foot.
C. Brudzinski's sign
Rationale: Brudzinski's sign is an indication of meningeal irritation, such as in clients who have meningitis.
With the client supine, the nurse should place one hand behind his head and places her other
hand on his chest. The nurse then raises the client's head with her hand behind his head, while
the hand on his chest restrains him and prevents him from rising. Flexion of the client's lower
extremities constitutes a positive sign.
D. Kernig's sign
Rationale: Kernig's sign is an indication of meningeal irritation, such as in clients who have meningitis.
The nurse performs the maneuver with the client supine with his hips and knees in flexion. The
inability to extend the client's knees fully without causing pain constitutes a positive test.
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23. A nurse is caring for a client who is 4 days postoperative following a right radical mastectomy. Which of the
following activities should the nurse anticipate being the most difficult for this client to perform with her right hand?
A. Buttoning her blouse
Rationale: Although this arm motion mainly involves the hand, wrist, and elbow of the affected arm, it is
not the most difficult for the client to perform.
B. Eating her breakfast
Rationale: Although this arm motion mainly involves the hand, wrist, and elbow of the affected arm, it is
not the most difficult for the client to perform.
C. Combing her hair
Rationale: Abduction of the arm is the most difficult, and usually the last, type of movement to be regained
by a client following a mastectomy.
D. Brushing her teeth
Rationale: Although this arm motion mainly involves the hand, wrist, and elbow of the affected arm, it is
not the most difficult for the client to perform.
24. A nurse is caring for an adolescent client who has a long history of diabetes mellitus and is being admitted to the
emergency department confused, flushed, and with an acetone odor on the breath. Diabetic ketoacidosis is
suspected. The nurse should anticipate using which of the following types of insulin to treat this client?
A. NPH insulin
Rationale: Isophane NPH insulin is intermediate-acting. It has an onset of action of 1 to 4 hr and is not
appropriate for emergency treatment of ketoacidosis.
B. Insulin glargine
Rationale: Insulin glargine is a long-acting insulin, with an onset of 2 to4 hr. It is not appropriate for
emergency treatment of ketoacidosis.
C. Insulin detemir
Rationale: Insulin detemir is an intermediate-acting insulin. It has an onset of action of 1 to 4 hr and is not
appropriate for emergency treatment of ketoacidosis.
D. Regular insulin
Rationale: Regular insulin is classified as a short-acting insulin. It can be given intravenously with an onset
of action of less than 30 min. This is the insulin that is most appropriate in emergency situations
of severe hyperglycemia or diabetic ketoacidosis.
25. A nurse is caring for a client who has a new diagnosis of myasthenia gravis. For which of the following
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manifestations should the nurse monitor?
A. Confusion
Rationale: Myasthenia gravis does not affect cognition, level of consciousness, or orientation.
B. Weakness
Rationale: Generalized weakness of the diaphragmatic and intercostal muscles may produce respiratory
distress or predispose the client to respiratory infections.
C. Increased intracranial pressure
Rationale: Myasthenia gravis does not affect pressure within the brain.
D. Increased urinary output
Rationale: Myasthenia gravis does not cause increased urine output.
26. A nurse is caring for a client who who has had a stroke involving the right hemisphere. Which of the following
alterations in function should the nurse expect?
A. Difficulty reading
Rationale: The left hemisphere is the center for language, mathematic skills and thinking analytically. A
client who is unable to read following a stroke would have involvement of the left hemisphere.
B. Inability to recognize his family members
Rationale: The right hemisphere is involved with visual and spatial awareness. A client who is unable to
recognize faces would have involvement with the right hemisphere.
C. Right hemiparesis
Rationale: The motor nerve fibers of the brain cross in the medulla, and a motor deficit on one side of the
body reflects damage to the upper motor neurons on the opposite side of the brain. A client
who has right hemiparesis would have involvement of the left hemisphere.
D. Aphasia
Rationale: The left hemisphere is the center for language, mathematic skills and thinking analytically. A
client who is unable to speak or understand language following a stroke would have
involvement of the left hemisphere.
27. A nurse is reviewing the CBC findings for a female client who is receiving combination chemotherapy for breast
cancer. Which of the following findings should the nurse report to the provider?
A. WBC 2300/mm3
Rationale: This WBC finding is below the expected reference range. Chemotherapy treatment can cause
leukopenia; the nurse should report this finding to the provider and implement precautions to
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protect the client from infection.
B. RBC 5 million/mm3
Rationale: This finding is within the expected reference range.
C. Hemoglobin 12 g/dL
Rationale: This finding is within the expected reference range.
D. Platelets 155,000/mm3
Rationale: This finding is within the expected reference range.
28. A nurse is caring for a client who is 5 hr postoperative following a transurethral resection of the prostate (TURP).
The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following
actions should the nurse take first?
A. Notify the provider.
Rationale: The nurse may need to notify the provider if unable to induce fluid flow from the catheter, or if
the output is bright rad and thick; however, the nurse should attempt a different intervention
first.
B. Check the tubing for kinks.
Rationale: When providing client care, the nurse should first use the least restrictive intervention;
therefore, the nurse should check the catheter tubing for kinks. The nurse must ensure
constant flow of the bladder irrigant into the catheter and outward drainage from the catheter to
prevent clotting, which could occlude the catheter lumen.
C. Adjust the rate of the bladder irrigant.
Rationale: The nurse may need to increase the rate of bladder irrigant to stimulate removal of urine and
clots; however, the nurse should use a less restrictive intervention first.
D. Irrigate the catheter.
Rationale: The nurse may need to irrigate the catheter to check for an internal obstruction; however, the
nurse should use a less restrictive intervention first.
29. A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions
should the nurse take first?
A. Turn the client's head to the side.
Rationale: The first action the nurse should take when using the airway, breathing, circulation approach to
client care is to turn the client's head to the side. This action keeps the client's airway clear of
secretion to prevent aspiration.
B. Check the client's motor strength.
Rationale:
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The nurse should check the client's motor strength as part of a neurovascular assessment
following the seizure; however, there is another action the nurse should take first.
C. Loosen the clothing around the client's waist.
Rationale: The nurse should loosen the clothing around the client's waist to protect the client from injury;
however, there is another action the nurse should take first.
D. Document the time the seizure began.
Rationale: The nurse should document the time the seizure began and ended to provide information to the
provider about the severity of the seizure; however, there is another action the nurse should
take first.
30. A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the
head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the
priority for assessment and intervention?
A. Airway obstruction
Rationale: When using the airway, breathing, circulation approach to client care, the nurse determines that
the priority risk is airway obstruction. Burns of the head, neck, and chest often involve damage
to the pulmonary tree due to heat as well as smoke and soot inhalation. This can result in
severe respiratory difficulty. Nursing measures to maintain a patent airway should take priority
in this client's care.
B. Infection
Rationale: Prevention of infection is essential throughout hospitalization and treatment; however, another
risk is the priority.
C. Fluid imbalance
Rationale: Adequate fluid replacement is essential throughout the acute phase of burn treatment;
however, another risk is the priority.
D. Paralytic ileus
Rationale: Paralytic ileus can develop during the acute phase of burn care and might require nasogastric
decompression; however, another risk is the priority.
31. A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse, "I
can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up." Which of the
following actions should the nurse take to help this client with tenacious bronchial secretions?
A. Maintaining a semi-Fowler's position as often as possible
Rationale: Although a semi-Fowler's position can help the client breathe more easily, it will not alter the
consistency of secretions.
B. Administering oxygen via nasal cannula at 2 L/min
Rationale:
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Administration of oxygen helps correct hypoxemia, but it will not alter the consistency of
secretions.
C. Helping the client select a low-salt diet
Rationale: Although a low-salt diet can help limit peripheral edema, it will not alter the consistency of
secretions.
D. Encouraging the client to drink 2 to 3 L of water daily
Rationale: COPD is a term for two diseases of the respiratory system: chronic bronchitis and emphysema.
Maintaining hydration through the consumption of adequate fluids will help liquefy thick
secretions and facilitate their expectoration.
32. A nurse in a clinic is reviewing the laboratory values of a client who has primary hypothyroidism. The nurse should
anticipate an elevation of which of the following laboratory values?
A. Thyroid stimulating hormone (TSH)
Rationale: The nurse should anticipate that TSH will be elevated.
B. Free T4
Rationale: The nurse should anticipate that the client's level of free T4 will be decreased.
C. Serum T4
Rationale: The nurse should anticipate that the client's serum T4 will be decreased.
D. Serum T3
Rationale: The nurse should anticipate that the client's level serum T3 will be decreased.
33. A nurse is caring for a client who is in the immediate postoperative period following a partial laryngectomy. Which
of the following parameters should the nurse assess first?
A. Pain severity
Rationale: The nurse should assess the client's pain level to help provide adequate pain management;
however, another assessment is the priority.
B. Wound drainage
Rationale: The nurse should assess the quantity and character of drainage from the surgical wound to
monitor for hemorrhage; however, another assessment is the priority.
C. Tissue integrity
Rationale: Head and neck surgeries often require tissue flaps to close the surgical wound. The nurse
should monitor color and capillary refill in the area of the flap(s) to help determine viability;
however, another assessment is the priority.
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D. Airway patency
Rationale: When using the airway, breathing, circulation approach to client care, the nurse determines that
the priority assessment is airway patency. After head and neck surgery, a major,
life-threatening complication is airway obstruction. The priority actions involve airway
maintenance and gas exchange.
34. A nurse is reviewing discharge instructions with a client following a right cataract extraction. Which of the following
instructions should the nurse include?
A. Sleep on the abdomen to facilitate wound healing.
Rationale: The client should be instructed to sleep on the back or the unaffected side to lessen pressure
on the affected eye. Sleeping on the abdomen is not recommended.
B. Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week.
Rationale: The nurse should instruct the client to avoid activities that increase intraocular pressure.
Therefore, the nurse should instruct the client to avoid lifting anything heavier than 4.5 kg (10
lb) for 1 week following surgery.
C. Bend at the waist to pick objects up from the floor.
Rationale: The nurse should instruct the client to avoid activities that increase intraocular pressure, such
as bending at the waist. The client should bend at the knees to pick objects up from the floor.
D. Notify the surgeon if white drainage develops on the eyelids.
Rationale: White, crusty drainage on the eye lid is an expected finding. The client should notify the
surgeon if she has green or yellow drainage on the eyelids or eyelashes.
35. A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect?
A. Dehydration
Rationale: Diabetes insipidus causes excessive excretion of dilute urine, resulting in dehydration.
B. Polyphagia
Rationale: Polyphagia is a finding of diabetes mellitus, not insipidus.
C. Hyperglycemia
Rationale: Hyperglycemia is a finding of diabetes mellitus, not diabetes insipidus.
D. Bradycardia
Rationale: Tachycardia, not bradycardia, is a manifestation of diabetes insipidus.
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AM RN CAPSTONE EXAM SUMMER 24
36. A nurse is assessing a client who is in skeletal traction. Which of the following findings should the nurse identify as
an indication of infection at the pin sites?
A. Serosanguineous drainage
Rationale: Purulent drainage, not serosanguineous drainage, from the pin sites is an indication of
infection.
B. Mild erythema
Rationale: Redness is an expected finding after pin insertion. Severe redness at the pin sites is an
indication of infection.
C. Warmth
Rationale: Warmth is an expected finding after pin insertion. Coolness of the extremity, however, could
indicate neurovascular compromise.
D. Fever
Rationale: Manifestations of inflammation and infection at the pin sites include fever, purulent drainage,
odor, loose pins, and tenting of the skin around the pin sites.
37. A nurse is caring for a client who is receiving a unit of packed red blood cells. Fifteen minutes following the start of
the transfusion, the nurse notes that the client is febrile, with chills and red-tinged urine. Which of the following
transfusion reactions should the nurse suspect?
A. Febrile
Rationale: A febrile transfusion reaction can occur in clients who have received multiple blood product
transfusions. It is a response in which anti-white blood cell (WBC) antibodies react with the
WBCs remaining in the blood product. This results in chills, fever, hypotension, tachycardia and
tachypnea. Clients who have a history of multiple blood product transfusions may receive
leukocyte reduced blood or single-donor HLA matched platelets along with a WBC filter to
prevent febrile reactions.
B. Allergic
Rationale: Allergic (anaphylactic) transfusion reactions occur most often in clients who have pre-existing
allergies. It is thought to be the result of a reaction to the plasma protein contained in the blood
product. Manifestations include urticaria, itching, and flushing. In extreme cases,
bronchospasm and laryngeal edema, and shock may occur. Onset may occur as late as 24 hr
following the transfusion. Clients who have a history of allergies may receive blood products in
which the WBCs, plasma, and immunoglobulin A has been removed or the client may be
pre-treated with antihistamines and corticosteroids.
C. Acute pain
Rationale: An acute pain transfusion reaction can occur during or following transfusion with blood
products. It manifests as severe chest, joint, and back pain, along with hypertension and
flushing of the face and neck. The client is often anxious. Acute pain transfusion reactions are
treated symptomatically with medications for pain and rigors.
D. Hemolytic
Rationale:
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AM RN CAPSTONE EXAM SUMMER 24
A hemolytic transfusion reaction occurs when antibodies in the recipient's blood react to foreign
blood cells introduced by the transfusion. The antibodies bind to the foreign cells and destroy
them in a process known as hemolysis. The destroyed cells are excreted by the kidneys
(hemoglobinuria), causing the red-tinged urine. Hemolytic transfusion reactions can result in
acute renal injury, disseminated intravascular coagulation, and circulatory collapse.
38. A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be
transported to the x-ray department. Which of the following actions should the nurse take?
A. Clamp the chest tube prior to transferring the client to a wheelchair.
Rationale: Clamping the tube can lead to a tension pneumothorax (collapse of the lung) due to increased
intrathoracic pressure from gas and fluid that cannot be drained from the pleural space.
B. Disconnect the chest tube from the drainage system during transport.
Rationale: The chest tube should not be disconnected from the drainage system.
C. Keep the drainage system below the level of the client's chest at all times.
Rationale: During transport, the drainage system should be kept below the level of the client's chest to
prevent air and drainage fluid from re-entering the thoracic cavity.
D. Empty the collection chamber prior to transport.
Rationale: Emptying the collection chamber prior to transport is unnecessary.
39. A nurse is caring for a client who is 1 day postoperative following a transsphenoidal hypophysectomy. While
assessing the client, the nurse notes a large area of clear drainage seeping from the nasal packing. Which of the
following should be the nurse’s initial action?
A. Document the amount of drainage.
Rationale: The nurse should document the amount of drainage along with the clarity to determine the
extent of the cerebral spinal fluid (CSF) leakage and the presence of blood or pus; however
there is another action that is priority.
B. Obtain a culture of the drainage.
Rationale: Although infection is a potential complication of the procedure, there is another action that is
priority.
C. Check the drainage for glucose.
Rationale: A potential complication of hypophysectomy is cerebral spinal fluid (CSF) leakage. Fluid
leakage from the nose is a sign that this complication has occurred. The first action the nurse
should take using the nursing process is to assess the drainage for the presence of glucose,
which would indicate that the drainage is CSF.
D. Notify the client's provider.
Rationale:
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AM RN CAPSTONE EXAM SUMMER 24
Although the provider should be notified of the findings, there is another action that is priority.
40. A nurse is completing discharge planning for a client who has bacterial endocarditis. The client will need to receive
12 weeks of antibiotic therapy. Which of the following venous access devices should the nurse identify as
appropriate for the client?
A. Short peripheral catheter
Rationale: A short peripheral catheter provides IV access that is appropriate for short term therapy. A
client who requires 12 weeks of IV antibiotic therapy would require a more permanent type of
device.
B. Implanted infusion port
Rationale: These lines are preferred for clients who need long-term, intermittent intravenous therapy such
as chemotherapy.
C. Peripherally inserted central catheter
Rationale: A peripherally inserted central catheter (PICC) line is the venous access device commonly
used when the client needs extended, but not permanent, intravenous access. The PICC line
may remain in place for weeks or months. PICC lines can also be used to draw blood samples
without the need for additional venipunctures.
D. Arteriovenous fistula
Rationale: An arteriovenous fistula is used for hemodialysis access. This is not considered a venous
access device for the administration of medications.
41. A nurse is caring for a client who reports a throbbing headache after a lumbar puncture. Which of the following
actions is most likely to facilitate resolution of the headache?
A. Administer pain medication.
Rationale: A spinal headache following a lumbar puncture develops due to a leaking of the cerebrospinal
fluid (CSF) which depletes the amount of circulating CSF and results in insufficient fluid to
maintain the mechanical stability of the brain. While a medication for pain may help control the
symptoms, it doesn't facilitate resolution of the headache.
B. Darken the client's room and close the door.
Rationale: The client who has a spinal headache experiences a throbbing headache that worsens with
sitting or standing and is the result of a decreased amount of circulating CSF. Darkening the
room and closing the door may assist in controlling the pain for the client who has a migraine,
but it is not useful in the client who has a spinal headache.
C. Increase fluid intake.
Rationale: The client who has had a lumbar puncture is at risk for continued leaking of CSF from the
puncture site. This results in a decreased amount of circulating CSF. Increasing fluids is helpful
in quickly replacing the cerebrospinal fluid that was removed during the procedure and
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AM RN CAPSTONE EXAM SUMMER 24
increasing fluids will facilitate resolution of the headache. The client should also be instructed to
remain in a prone position for 6 hours to prevent leaking of CSF fluid.
D. Elevate the head of the bed to 30º.
Rationale: The client who has a spinal headache experiences a throbbing headache that worsens with
sitting or standing and is the result of a decreased amount of circulating CSF. Resolution of the
discomfort will occur by placing the client in a prone position. A client who has increased
intracranial pressure would be placed in a position with the head of the bed at 30º.
42. A nurse is caring for a client who has nephrotic syndrome and is receiving high-dose corticosteroid therapy. For
which of the following electrolyte imbalances should the nurse monitor?
A. Hypermagnesemia
Rationale: Nephrotic syndrome is a renal condition in which glomerular permeability is increased, resulting
in a loss of albumin (hypoalbuminemia). The nurse should be cautious when administering
magnesium to a client who has renal failure, as this can result in hypermagnesemia; however,
corticosteroids do not affect magnesium levels.
B. Hypokalemia
Rationale: If the nephrotic syndrome is immunologic in origin, it is often treated with the administration of
corticosteroids such as methylprednisolone. Corticosteroid use can lead to hypokalemia, which
features manifestations of muscle weakness and cardiac arrhythmia.
C. Hyperkalemia
Rationale: Corticosteroids such as methylprednisolone decrease inflammation and increase capillary
stability, allowing the kidneys to hold onto proteins. One of the side effects the nurse should
monitor the client receiving corticosteroids for is a loss of potassium.
D. Hypomagnesemia
Rationale: The nurse should monitor the client receiving corticosteroids for the development of adrenal
insufficiency as this medication suppresses adrenal function, which may cause hyponatremia;
however, corticosteroids do not affect magnesium levels.
43. A client is prescribed 1 g potassium phosphate IV to be infused continuously over 6 hr. Available is 1 g potassium
phosphate in 250 mL dextrose 5% water (D5W). The nurse should set the IV pump to run at how many mL/hr?
(Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
42 mL/hr
Correct Rationale: Follow these steps to calculate the infusion rate using the Ratio and Proportion or
Desired Over Have method of calculation:Step 1: What is the unit of measurement
the nurse should calculate? mL/hr Step 2: What is the volume the nurse should infuse?
250 mL Step 3: What is the total infusion time? 6 hr Step 4: Should the nurse convert the
units of measurement? No Step 5: Set up an equation and solve for X. Volume
(mL)X mL/hr =
Time (hr)250 mLX mL/hr =
6 hrX mL/hr = 41.6666 mL/hrStep 6: Round if Created on:09/05/2024 Page 18 Detailed Answer Key AM RN CAPSTONE EXAM SUMMER 24 ortion or Desired Over Have method of calculation:Step 1: What is the unit of measurement the nurse should calculate? mL/hr Step 2: What is the volume the nurse should infuse? 250 mL Step 3: What is the total infusion time? 6 hr Step 4: Should the nurse convert the units of measurement? No Step 5: Set up an equation and solve for X. Volume (mL)X mL/hr =
Time (hr)250 mLX mL/hr =
6 hrX mL/hr = 41.6666 mL/hrStep 6: Round if necessary. 41.6666 = 42 mL/hrStep 7: Reassess to determine whether the amount to administer makes sense. If the prescription reads 1 g potassium phosphate in D5W 250 mL IV to infuse over 6 hr, it makes sense to administer 42 mL/hr. The nurse should set the IV pump to deliver 1 g potassium phosphate in D5W 250 mL IV at 42 mL/hr. Follow these steps to calculate the infusion rate using the Dimensional Analysis method of calculation:Step 1: What is the unit of measurement the nurse should calculate? (Place the unit of measure being calculated on the left side of the equation.) X mL/hr = Step 2: Determine the ratio that contains the same unit as the unit being calculated. (Place the ratio on the right side of the equation, ensuring that the unit in the numerator matches the unit being calculated.) 250 mLX mL/hr =
6 hrStep 3: Place any remaining ratios that are relevant to the item on the right side of the equation, along with any needed conversion factors, to cancel out unwanted units of measurement. 250 mLX mL/hr =
6 hrStep 4: Solve for X. X mL/hr = 41.6666 mL/hrStep 5: Round if necessary. 41.6666 = 42 mL/hrStep 6: Reassess to determine whether the amount to administer makes sense. If the prescription reads 1 g potassium phosphate in D5W 250 mL IV to infuse over 6 hr, it makes sense to administer 42 mL/hr. The nurse should set the IV pump to deliver 1 g potassium phosphate in D5W 250 mL IV at 42 mL/hr. InCorrect Rationale: Follow these steps to calculate the infusion rate using the Ratio and Proportion or Desired Over Have method of calculation:Step 1: What is the unit of measurement the nurse should calculate? mL/hr Step 2: What is the volume the nurse should infuse? 250 mL Step 3: What is the total infusion time? 6 hr Step 4: Should the nurse convert the units of measurement? No Step 5: Set up an equation and solve for X. Volume (mL)X mL/hr =
Time (hr)250 mLX mL/hr =
6 hrX mL/hr = 41.6666 mL/hrStep 6: Round if necessary. 41.6666 = 42 mL/hrStep 7: Reassess to determine whether the amount to administer makes sense. If the prescription reads 1 g potassium phosphate in D5W 250 mL IV to infuse over 6 hr, it makes sense to administer 42 mL/hr. The nurse should set the IV pump to deliver 1 g potassium phosphate in D5W 250 mL IV at 42 mL/hr. Follow these steps to calculate the infusion rate using the Dimensional Analysis method of calculation:Step 1: What is the unit of measurement the nurse should calculate? (Place the unit of measure being calculated on the left side of the equation.) X mL/hr = Step 2: Determine the ratio that contains the same unit as the unit being calculated. (Place the ratio on the right side of the equation, ensuring that the unit in the numerator matches the unit being calculated.) 250 mLX mL/hr =
6 hrStep 3: Place any remaining ratios that are relevant to the item on the right side of the equation, along with any needed conversion factors, to cancel out unwanted units of measurement. 250 mLX mL/hr =
6 hrStep 4: Solve for X. X mL/hr = 41.6666 mL/hrStep 5: Round if necessary. 41.6666 = 42 mL/hrStep 6: Reassess to determine whether the amount to administer makes sense. If the prescription reads 1 g potassium phosphate in D5W 250 mL IV to infuse over 6 hr, it makes sense to administer 42 mL/hr. The nurse should set the IV pump to deliver 1 g potassium phosphate in D5W 250 mL IV at 42 mL/hr. 44. A nurse is preparing to start an IV infusion of lactated Ringer's for a client who sustained a burn injury. The client is prescribed 5,200 mL of fluid over the first 24 hr. How many mL/hr should the nurse set the pump to infuse for the Created on:09/05/2024 Page 19 Detailed Answer Key AM RN CAPSTONE EXAM SUMMER 24 first 8 hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) 325 ml/hr Correct Rationale: Follow these steps to calculate the infusion rate using the Ratio and Proportion or Desired Over Have method of calculation:The nurse should infuse half of the total volume prescribed for 24 hr for a client who has sustained a burn injury over the first 8 hr. Therefore, the nurse should complete the calculation using half of 5,200 mL, which is 2,600 mL.Step 1: What is the unit of measurement the nurse should calculate? mL/hr Step 2: What is the volume the nurse should infuse? 2,600 mL Step 3: What is the total infusion time? 8 hr Step 4: Should the nurse convert the units of measurement? No Step 5: Set up an equation and solve for X. Volume (mL)X mL/hr =
Time (hr)2,600 mLX mL/hr =
8 hrX mL/hr = 325 mL/hrStep 6: Round if necessary. Step 7: Reassess to determine if the amount to administer makes sense. If the amount prescribed is 2,600 mL to infuse over 8 hr, it makes sense to administer 325 mL/hr. Follow these steps to calculate the infusion rate using the Dimensional Analysis method of calculation:The nurse should infuse half of the total volume prescribed for 24 hr for a client who has sustained a burn injury over the first 8 hr. Therefore, the nurse should complete the calculation using half of 5,200 mL, which is 2,600 mL.Step 1: What is the unit of measurement the nurse should calculate? (Place the unit of measure being calculated on the left side of the equation.) X mL/hr = Step 2: Determine the ratio that contains the same unit as the unit being calculated. (Place the ratio on the right side of the equation, ensuring that the unit in the numerator matches the unit being calculated.) 2,600 mLX mL/hr =
8 hrStep 3: Place any remaining ratios that are relevant to the item on the right side of the equation, along with any needed conversion factors, to cancel out unwanted units of measurement. 2,600 mLX mL/hr =
8 hrStep 4: Solve for X. X mL/hr = 325 mL/hrStep 5: Round if necessary. Step 6: Reassess to determine if the amount to administer makes sense. If the amount prescribed is 2,600 mL to infuse over 8 hr, it makes sense to administer 325 mL/hr. InCorrect Rationale: Follow these steps to calculate the infusion rate using the Ratio and Proportion or Desired Over Have method of calculation:The nurse should infuse half of the total volume prescribed for 24 hr for a client who has sustained a burn injury over the first 8 hr. Therefore, the nurse should complete the calculation using half of 5,200 mL, which is 2,600 mL.Step 1: What is the unit of measurement the nurse should calculate? mL/hr Step 2: What is the volume the nurse should infuse? 2,600 mL Step 3: What is the total infusion time? 8 hr Step 4: Should the nurse convert the units of measurement? No Step 5: Set up an equation and solve for X. Volume (mL)X mL/hr =
Time (hr)2,600 mLX mL/hr =
8 hrX mL/hr = 325 mL/hrStep 6: Round if necessary. Step 7: Reassess to determine if the amount to administer makes sense. If the amount prescribed is 2,600 mL to infuse over 8 hr, it makes sense to administer 325 mL/hr. Follow these steps to calculate the infusion rate using the Dimensional Analysis method of calculation:The nurse should infuse half of the total volume prescribed for 24 hr for a client who has sustained a burn injury over the first 8 hr. Therefore, the nurse should complete the calculation using half of 5,200 mL, which is 2,600 mL.Step 1: What is the unit of measurement the nurse should calculate? (Place the unit of measure being calculated on the left side of the equation.) X mL/hr = Step 2: Determine the ratio that contains the same unit as the unit being calculated. (Place the ratio on the right side of the equation, ensuring that the unit in the numerator matches the unit being calculated.) 2,600 mLX mL/hr =
8 hrStep 3: Place any remaining ratios that are relevant to the item on the right side of the equation, along with any needed conversion factors, to cancel out unwanted units of measurement. 2,600 mLX mL/hr =
8 hrStep 4: Created on:09/05/2024 Page 20 Detailed Answer Key AM RN CAPSTONE EXAM SUMMER 24 o and Proportion or Desired Over Have method of calculation:The nurse should infuse half of the total volume prescribed for 24 hr for a client who has sustained a burn injury over the first 8 hr. Therefore, the nurse should complete the calculation using half of 5,200 mL, which is 2,600 mL.Step 1: What is the unit of measurement the nurse should calculate? mL/hr Step 2: What is the volume the nurse should infuse? 2,600 mL Step 3: What is the total infusion time? 8 hr Step 4: Should the nurse convert the units of measurement? No Step 5: Set up an equation and solve for X. Volume (mL)X mL/hr =
Time (hr)2,600 mLX mL/hr =
8 hrX mL/hr = 325 mL/hrStep 6: Round if necessary. Step 7: Reassess to determine if the amount to administer makes sense. If the amount prescribed is 2,600 mL to infuse over 8 hr, it makes sense to administer 325 mL/hr. Follow these steps to calculate the infusion rate using the Dimensional Analysis method of calculation:The nurse should infuse half of the total volume prescribed for 24 hr for a client who has sustained a burn injury over the first 8 hr. Therefore, the nurse should complete the calculation using half of 5,200 mL, which is 2,600 mL.Step 1: What is the unit of measurement the nurse should calculate? (Place the unit of measure being calculated on the left side of the equation.) X mL/hr = Step 2: Determine the ratio that contains the same unit as the unit being calculated. (Place the ratio on the right side of the equation, ensuring that the unit in the numerator matches the unit being calculated.) 2,600 mLX mL/hr =
8 hrStep 3: Place any remaining ratios that are relevant to the item on the right side of the equation, along with any needed conversion factors, to cancel out unwanted units of measurement. 2,600 mLX mL/hr =
8 hrStep 4: Solve for X. X mL/hr = 325 mL/hrStep 5: Round if necessary. Step 6: Reassess to determine if the amount to administer makes sense. If the amount prescribed is 2,600 mL to infuse over 8 hr, it makes sense to administer 325 mL/hr. 45. A nurse is preparing to administer 250 mg of an antibiotic IM. Available is 3 g/5 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) 0.4 mL Correct Rationale: Follow these steps for the Ratio and Proportion method of calculation:Step 1: What is the unit of measurement the nurse should calculate? mL Step 2: What is the dose the nurse should administer? Dose to administer = Desired 250 mg Step 3: What is the dose available? Dose available = Have 3 g Step 4: Should the nurse convert the units of measurement? Yes (g does not equal mg) 1 g 3 g
=
1,000 mgX mgX mg = 3,000 mgStep 5: What is the quantity of the dose available? 5 mL Step 6: Set up an equation and solve for X. HaveDesired
=
QuantityX3,000 mg250 mg
=
5 mLX mLX mL = 0.4166 mLStep 7: Round if necessary. 0.4166 = 0.4 mLStep 8: Determine whether the amount to administer makes sense. If there is 3 g (3,000 mg) in 5 mL and the prescription reads 250 mg, it makes sense to administer 0.4 mL. The nurse should administer 0.4 mL IM.Follow these steps for the Desired Over Have method of calculation:Step 1: What is the unit of measurement the nurse should calculate? mL Step 2: What is the dose the nurse should administer? Dose to administer = Desired 250 mg Step 3: What is the dose available? Dose available = Have 3 g Step 4: Should the nurse convert the units of measurement? Yes (g does not equal mg) 3g × 1,000 mgX mg =
1gX
mg = 3,000 mgStep 5: What is the quantity of the dose available? 5 mL Step 6: Set up an
equation and solve for X. Desired × QuantityX =
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AM RN CAPSTONE EXAM SUMMER 24
n:Step 1: What is the unit of measurement the nurse should calculate? mL Step 2:
What is the dose the nurse should administer? Dose to administer = Desired 250 mg
Step 3: What is the dose available? Dose available = Have 3 g Step 4: Should the nurse
convert the units of measurement? Yes (g does not equal mg) 1 g 3 g
=
1,000 mgX mgX mg = 3,000 mgStep 5: What is the quantity of the dose available? 5 mL Step 6: Set up an equation and solve for X. HaveDesired
=
QuantityX3,000 mg250 mg
=
5 mLX mLX mL = 0.4166 mLStep 7: Round if necessary. 0.4166 = 0.4 mLStep 8: Determine whether the amount to administer makes sense. If there is 3 g (3,000 mg) in 5 mL and the prescription reads 250 mg, it makes sense to administer 0.4 mL. The nurse should administer 0.4 mL IM.Follow these steps for the Desired Over Have method of calculation:Step 1: What is the unit of measurement the nurse should calculate? mL Step 2: What is the dose the nurse should administer? Dose to administer = Desired 250 mg Step 3: What is the dose available? Dose available = Have 3 g Step 4: Should the nurse convert the units of measurement? Yes (g does not equal mg) 3g × 1,000 mgX mg =
1gX
mg = 3,000 mgStep 5: What is the quantity of the dose available? 5 mL Step 6: Set up an
equation and solve for X. Desired × QuantityX =
Have250mg × 5 mLX mL =
3,000mgX mL = 0.41666 mLStep 7: Round if necessary.
0.41666 = 0.4 mLStep 8: Determine whether the amount to administer makes sense. If
there is 3 g (3,000 mg) in 5 mL and the prescription reads 250 mg, it makes sense to
administer 0.4 mL. The nurse should administer 0.4 mL IM.Follow these steps for the
Dimensional Analysis method of calculation:Step 1: What is the unit of measurement
the nurse should calculate? (Place the unit of measure being calculated on the left side of
the equation.) X mL = Step 2: Determine the ratio that contains the same unit as
the unit being calculated. (Place the ratio on the right side of the equation, ensuring that
the unit in the numerator matches the unit being calculated.) 5 mLX mL =
3 gStep 3: Place any remaining ratios that are relevant to the item on the right side of the equation, along with any needed conversion factors, to cancel out unwanted units of measurement. 5 mL1g250 mgX mL =
×
×
3g1,000 mg 1
Step 4: Solve for X. X mL = 0.4166 mLStep 5: Round if necessary.
0.4166 = 0.4 mL Step 6: Determine whether the amount to administer makes sense. If
there is 3 g (3,000 mg) in 5 mL and the prescription reads 250 mg, it makes sense to
administer 0.4 mL. The nurse should administer 0.4 mL IM.
InCorrect Rationale: Follow these steps for the Ratio and Proportion method of calculation:Step 1:
What is the unit of measurement the nurse should calculate? mL Step 2: What is the
dose the nurse should administer? Dose to administer = Desired 250 mg Step 3: What
is the dose available? Dose available = Have 3 g Step 4: Should the nurse convert the
units of measurement? Yes (g does not equal mg) 1 g 3 g
=
1,000 mgX mgX mg = 3,000 mgStep 5: What is the quantity of the dose available? 5 mL Step 6: Set up an equation and solve for X. HaveDesired
=
QuantityX3,000 mg250 mg
=
5 mLX mLX mL = 0.4166 mLStep 7: Round if necessary. 0.4166 = 0.4 mLStep 8: Determine whether the amount to administer makes sense. If there is 3 g (3,000 mg) in 5 mL and the prescription reads 250 mg, it makes sense to administer 0.4 mL. The nurse should administer 0.4 mL IM.Follow these steps for the Desired Over Have method of calculation:Step 1: What is the unit of measurement the nurse should calculate? mL Step 2: What is the dose the nurse should administer? Dose to administer = Desired 250 mg Step 3: What is the dose available? Dose available = Have 3 g Step 4: Should the nurse convert the units of measurement? Yes (g does not equal mg) 3g × 1,000 mgX
mg =
1gX mg = 3,000 mgStep 5: What is the
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AM RN CAPSTONE EXAM SUMMER 24
on:Step 1: What is the unit of measurement the nurse should calculate? mL Step
2: What is the dose the nurse should administer? Dose to administer = Desired 250 mg
Step 3: What is the dose available? Dose available = Have 3 g Step 4: Should the
nurse convert the units of measurement? Yes (g does not equal mg) 1 g 3 g
=
1,000 mgX mgX mg = 3,000 mgStep 5: What is the quantity of the dose available? 5 mL Step 6: Set up an equation and solve for X. HaveDesired
=
QuantityX3,000 mg250 mg
=
5 mLX mLX mL = 0.4166 mLStep 7: Round if necessary. 0.4166 = 0.4 mLStep 8: Determine whether the amount to administer makes sense. If there is 3 g (3,000 mg) in 5 mL and the prescription reads 250 mg, it makes sense to administer 0.4 mL. The nurse should administer 0.4 mL IM.Follow these steps for the Desired Over Have method of calculation:Step 1: What is the unit of measurement the nurse should calculate? mL Step 2: What is the dose the nurse should administer? Dose to administer = Desired 250 mg Step 3: What is the dose available? Dose available = Have 3 g Step 4: Should the nurse convert the units of measurement? Yes (g does not equal mg) 3g × 1,000 mgX
mg =
1gX mg = 3,000 mgStep 5: What is the
quantity of the dose available? 5 mL Step 6: Set up an equation and solve for X.
Desired × QuantityX =
Have250mg × 5 mLX mL =
3,000mgX mL = 0.41666 mLStep 7: Round if
necessary. 0.41666 = 0.4 mLStep 8: Determine whether the amount to administer
makes sense. If there is 3 g (3,000 mg) in 5 mL and the prescription reads 250 mg, it
makes sense to administer 0.4 mL. The nurse should administer 0.4 mL IM.Follow
these steps for the Dimensional Analysis method of calculation:Step 1: What is the
unit of measurement the nurse should calculate? (Place the unit of measure being
calculated on the left side of the equation.) X mL = Step 2: Determine the ratio
that contains the same unit as the unit being calculated. (Place the ratio on the right
side of the equation, ensuring that the unit in the numerator matches the unit being
calculated.) 5 mLX mL =
3 gStep 3: Place any remaining ratios that are relevant to the item on the right side of the equation, along with any needed conversion factors, to cancel out unwanted units of measurement. 5 mL1g250 mgX mL =
×
×
3g1,000 mg 1 Step 4: Solve for X. X mL =
0.4166 mLStep 5: Round if necessary. 0.4166 = 0.4 mL Step 6: Determine whether the
amount to administer makes sense. If there is 3 g (3,000 mg) in 5 mL and the
prescription reads 250 mg, it makes sense to administer 0.4 mL. The nurse should
administer 0.4 mL IM.
46. A nurse is preparing to administer heparin 2,000 units by IV bolus. Available is heparin injection 5,000 units/mL.
How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it
applies. Do not use a trailing zero.)
0.4 mL
Correct Rationale: Follow these steps for the Ratio and Proportion method of calculation:Step 1:
What is the unit of measurement the nurse should calculate? mL Step 2: What is the dose
the nurse should administer? Dose to administer = Desired 2,000 units Step 3: What is
the dose available? Dose available = Have 5,000 units Step 4: Should the nurse convert
the units of measurement? No Step 5: What is the quantity of the dose available? 1 mL
Step 6: Set up an equation and solve for X. HaveDesired
=
QuantityX5,000 units2,000 units
=
1 mLX mLX mL = 0.4 mLStep 7: Round if necessary. Created on:09/05/2024 Page 23 Detailed Answer Key AM RN CAPSTONE EXAM SUMMER 24 t;/b>Step 1: What is the unit of measurement the nurse should calculate? mL Step 2: What is the dose the nurse should administer? Dose to administer = Desired 2,000 units Step 3: What is the dose available? Dose available = Have 5,000 units Step 4: Should the nurse convert the units of measurement? No Step 5: What is the quantity of the dose available? 1 mL Step 6: Set up an equation and solve for X. HaveDesired
=
QuantityX5,000 units2,000 units
=
1 mLX mLX mL = 0.4 mLStep 7: Round if necessary. Step 8: Reassess to determine whether the amount to administer makes sense. If there are 5,000 units/mL and the provider prescribed 2,000 units, it makes sense to administer 0.4 mL. The nurse should administer heparin 0.4 mL by IV bolus.Follow these steps for the Desired Over Have method of calculation:Step 1: What is the unit of measurement the nurse should calculate? mL Step 2: What is the dose the nurse should administer? Dose to administer = Desired 2,000 units Step 3: What is the dose available? Dose available = Have 5,000 units Step 4: Should the nurse convert the units of measurement? No Step 5: What is the quantity of the dose available? 1 mL Step 6: Set up an equation and solve for X. Desired × QuantityX =
Have2,000units × 1 mLX mL =
5,000unitsX mL = 0.4 mLStep 7: Round if necessary.
Step 8: Reassess to determine whether the amount to administer makes sense. If there
are 5,000 units/mL and the provider prescribed 2,000 units, it makes sense to administer
0.4 mL. The nurse should administer heparin 0.4 mL by IV bolus. Follow these steps
for the Dimensional Analysis method of calculation:Step 1: What is the unit of
measurement the nurse should calculate? (Place the unit of measure being calculated on
the left side of the equation.) X mL = Step 2: Determine the ratio that contains the
same unit as the unit being calculated. (Place the ratio on the right side of the equation,
ensuring that the unit in the numerator matches the unit being calculated.) 1 mLX
mL =
5,000 unitsStep 3: Place any remaining ratios that are relevant to the item on the right side of the equation, along with any needed conversion factors, to cancel out unwanted units of measurement. 1 mL2,000unitsX
mL =
×
5,000units1 Step 4: Solve
for X. X mL = 0.4 mLStep 5: Round if necessary. Step 6: Determine whether the
amount to administer makes sense. If there is 5,000 units per mL and the prescription
reads 2,000 units, it makes sense to administer 0.4 mL. The nurse should administer
heparin 0.4 mL by IV bolus.
InCorrect Rationale: Follow these steps for the Ratio and Proportion method of calculation:Step 1:
What is the unit of measurement the nurse should calculate? mL Step 2: What is the
dose the nurse should administer? Dose to administer = Desired 2,000 units Step 3:
What is the dose available? Dose available = Have 5,000 units Step 4: Should the
nurse convert the units of measurement? No Step 5: What is the quantity of the dose
available? 1 mL Step 6: Set up an equation and solve for X.
HaveDesired
=
QuantityX5,000 units2,000 units
=
1 mLX mLX mL = 0.4 mLStep 7: Round if necessary. Step 8: Reassess to determine whether the amount to administer makes sense. If there are 5,000 units/mL and the provider prescribed 2,000 units, it makes sense to administer 0.4 mL. The nurse should administer heparin 0.4 mL by IV bolus.Follow these steps for the Desired Over Have method of calculation:Step 1: What is the unit of measurement the nurse should calculate? mL Step 2: What is the dose the nurse should administer? Dose to administer = Desired 2,000 units Step 3: What is the dose available? Dose available = Have 5,000 units Step 4: Should the nurse convert the units of measurement? No Step 5: What is the quantity of the dose available? 1 mL Step 6: Set up an equation and solve for X. Desired × QuantityX =
Have2,000units
× 1 mLX mL =
5,000unitsX mL =
0.4 mLStep 7: Round if necessary. Step 8: Reassess to determine whether the amount
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AM RN CAPSTONE EXAM SUMMER 24
to administer makes sense. If there are 5,000 units/mL and the provider prescribed
2,000 units, it makes sense to administer 0.4 mL. The nurse should administer heparin
0.4 mL by IV bolus.Follow these steps for the Desired Over Have method of
calculation:Step 1: What is the unit of measurement the nurse should calculate?
mL Step 2: What is the dose the nurse should administer? Dose to administer =
Desired 2,000 units Step 3: What is the dose available? Dose available = Have 5,000
units Step 4: Should the nurse convert the units of measurement? No Step 5: What is
the quantity of the dose available? 1 mL Step 6: Set up an equation and solve for X.
Desired × QuantityX =
Have2,000units × 1 mLX mL =
5,000unitsX mL = 0.4 mLStep 7: Round if necessary.
Step 8: Reassess to determine whether the amount to administer makes sense. If there
are 5,000 units/mL and the provider prescribed 2,000 units, it makes sense to
administer 0.4 mL. The nurse should administer heparin 0.4 mL by IV bolus. Follow
these steps for the Dimensional Analysis method of calculation:Step 1: What is the
unit of measurement the nurse should calculate? (Place the unit of measure being
calculated on the left side of the equation.) X mL = Step 2: Determine the ratio
that contains the same unit as the unit being calculated. (Place the ratio on the right
side of the equation, ensuring that the unit in the numerator matches the unit being
calculated.) 1 mLX mL =
5,000 unitsStep 3: Place any remaining ratios that are relevant to the item on the right side of the equation, along with any needed conversion factors, to cancel out unwanted units of measurement. 1 mL2,000unitsX mL =
×
5,000units1 Step 4: Solve for X. X mL = 0.4 mLStep 5:
Round if necessary. Step 6: Determine whether the amount to administer makes
sense. If there is 5,000 units per mL and the prescription reads 2,000 units, it makes
sense to administer 0.4 mL. The nurse should administer heparin 0.4 mL by IV bolus.
47. A nurse is preparing to administer metoprolol 5 mg IV bolus to a client for heart rate control. Available is metoprolol
injection 1 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole
number. Use a leading zero if it applies. Do not use a trailing zero.)
5 mL
Correct Rationale: Follow these steps for the Ratio and Proportion method of calculation:Step 1:
What is the unit of measurement the nurse should calculate? mL Step 2: What is the dose
the nurse should administer? Dose to administer = Desired 5 mg Step 3: What is the
dose available? Dose available = Have 1 mg Step 4: Should the nurse convert the units
of measurement? No Step 5: What is the quantity of the dose available? 1 mL Step 6: Set
up an equation and solve for X. HaveDesired
=
QuantityX1 mg5 mg
=
1 mLX mLX mL = 5 mLStep 7: Round if necessary. Step 8: Reassess to determine whether the amount to administer makes sense. If there is 1 mg/mL and the prescription reads 5 mg, it makes sense to administer 5 mL. The nurse should administer metoprolol 5 mL IV per dose.Follow these steps for the Desired Over Have method of calculation:Step 1: What is the unit of measurement the nurse should calculate? mL Step 2: What is the dose the nurse should administer? Dose to administer = Desired 5 mg Step 3: What is the dose available? Dose available = Have 1 mg Step 4: Should the nurse convert the units of measurement? No Step 5: What is the quantity of the dose available? 1 mL Step 6: Set up an equation and solve for X. Desired × QuantityX =
Have5mg × 1 mLX mL =
1mgX mL = 5 mLStep 7: Round if necessary. Step 8: Reassess to
determine whether the amount to administer makes sense. If there is 1 mg/mL and the
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AM RN CAPSTONE EXAM SUMMER 24
prescription reads 5 mg, it makes sense to administer 5 mL. The nurse should administer
metoprolol 5 mL IV per dose. Follow these steps for the Dimensional Analysis
method of calculation:Step 1: What is the unit of measurement the nurse should
calculate? (Place the unit of measure being calculated on the left side of the equation.)
X mL = Step 2: Determine the ratio that contains the same unit as the unit being
calculated. (Place the ratio on the right side of the equation, ensuring that the unit in the
numerator matches the unit being calculated.) 1 mLX mL =
1 mgStep 3: Place any remaining ratios that are relevant to the item on the right side of the equation, along with any needed conversion factors, to cancel out unwanted units of measurement. 1 mL5mgX mL =
×
1mg1 Step 4: Solve for X. X mL = 5 mLStep 5: Round if
necessary. Step 6: Reassess to determine whether the amount to administer makes
sense. If there is 1 mg/mL and the prescription reads 5 mg, it makes sense to administer
5 mL. The nurse should administer metoprolol 5 mL IV per dose.
InCorrect Rationale: Follow these steps for the Ratio and Proportion method of calculation:Step 1:
What is the unit of measurement the nurse should calculate? mL Step 2: What is the
dose the nurse should administer? Dose to administer = Desired 5 mg Step 3: What is
the dose available? Dose available = Have 1 mg Step 4: Should the nurse convert the
units of measurement? No Step 5: What is the quantity of the dose available? 1 mL
Step 6: Set up an equation and solve for X. HaveDesired
=
QuantityX1 mg5 mg
=
1 mLX mLX mL = 5 mLStep 7: Round if necessary. Step 8: Reassess to determine whether the amount to administer makes sense. If there is 1 mg/mL and the prescription reads 5 mg, it makes sense to administer 5 mL. The nurse should administer metoprolol 5 mL IV per dose.Follow these steps for the Desired Over Have method of calculation:Step 1: What is the unit of measurement the nurse should calculate? mL Step 2: What is the dose the nurse should administer? Dose to administer = Desired 5 mg Step 3: What is the dose available? Dose available = Have 1 mg Step 4: Should the nurse convert the units of measurement? No Step 5: What is the quantity of the dose available? 1 mL Step 6: Set up an equation and solve for X. Desired × QuantityX =
Have5mg × 1 mLX mL =
1mgX mL = 5 mLStep 7: Round if necessary. Step 8:
Reassess to determine whether the amount to administer makes sense. If there is 1
mg/mL and the prescription reads 5 mg, it makes sense to administer 5 mL. The nurse
should administer metoprolol 5 mL IV per dose. Follow these steps for the
Dimensional Analysis method of calculation:Step 1: What is the unit of
measurement the nurse should calculate? (Place the unit of measure being calculated
on the left side of the equation.) X mL = Step 2: Determine the ratio that
contains the same unit as the unit being calculated. (Place the ratio on the right side of
the equation, ensuring that the unit in the numerator matches the unit being calculated.)
1 mLX mL =
1 mgStep 3: Place any remaining ratios that are relevant to the item on the right side of the equation, along with any needed conversion factors, to cancel out unwanted units of measurement. 1 mL5mgX mL =
×
1mg1
Step 4: Solve for X. X mL = 5 mLStep 5: Round if necessary. Step 6:
Reassess to determine whether the amount to administer makes sense. If there is 1
mg/mL and the prescription reads 5 mg, it makes sense to administer 5 mL. The nurse
should administer metoprolol 5 mL IV per dose.
48. A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the
nurse take?
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AM RN CAPSTONE EXAM SUMMER 24
A. Secure the restraints using a quick-release tie.
Rationale: The nurse should secure the restraints using a quick-release tie for easy removal in an
emergency.
B. Ensure four fingers fit under the restraints to prevent constriction.
Rationale: The nurse should prevent constriction by inserting two fingers under the restraints. The
restraint might be ineffective if the nurse can insert four fingers under it.
C. Secure the restraints to the lowest bar of the side rail.
Rationale: The nurse should secure the restraints to an area of the bed frame that moves with the client
when repositioning, such as raising and lowering the head of the bed. The nurse should not
secure the restraints to the side rail.
D. Anticipate removing the restraints every 4 hr.
Rationale: The nurse should remove the restraints at least every 2 hr or more frequently according to
facility policy.
49. A client smoking in his bathroom has dropped a cigarette butt into a wastepaper basket, which begins to smolder.
Which of the following actions is the nurse’s priority?
A. Close the fire doors on the unit.
Rationale: Clients are at risk for injury because the smoke and fire could spread through open doors;
however, another action is the priority.
B. Activate the fire alarm.
Rationale: Clients are at risk for injury because the smoke and fire could spread without emergency
services intervention; however, another action is the priority.
C. Move any clients in the immediate vicinity.
Rationale: The greatest risk to clients is injury from smoke and fire; therefore, the nurse’s first action is to
move any clients near the smoke to a safe location. The acronym RACE is a reminder of the
order in which to take steps in the event of a fire. The nurse should rescue the clients, activate
the fire alarm, confine the fire, and extinguish the fire.
D. Use a fire extinguisher to put out the fire.
Rationale: Clients are at risk for injury unless someone extinguishes the fire; however, another action is
the priority.
50. A nurse is assessing a client and discovers the infusion pump with the client’s total parenteral nutrition (TPN)
solution is not infusing. The nurse should monitor the client for which of the following conditions?
A. Excessive thirst and urination
Rationale:
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AM RN CAPSTONE EXAM SUMMER 24
Excessive thirst and urination are manifestations of hyperglycemia, which can be a
complication of TPN related to the high proportion of glucose in the infusion.
B. Shakiness and diaphoresis
Rationale: When a sudden interruption in the infusion of TPN occurs, the client is at risk for hypoglycemia.
Shakiness and diaphoresis are manifestations of hypoglycemia.
C. Fever and chills
Rationale: Fever and chills are manifestations of infection.
D. Hypertension and crackles
Rationale: Hypertension and crackles are manifestations of fluid overload, which can be a complication of
TPN related to the fluid infusion rate.
51. A nurse is caring for a client who has had an allogeneic hematopoietic stem-cell transplant. Which of the following
infection-control precautions should the nurse use while caring for this client?
A. Airborne
Rationale: Clients who have varicella and other infections such as rubeola and tuberculosis require
airborne precautions.
B. Protective
Rationale: Clients whose immune system is compromised, such as from chemotherapy, AIDS, or after a
stem-cell transplant, require a protective environment.
C. Contact
Rationale: Clients who have infections such as herpes simplex, respiratory syncytial virus, and
methicillin-resistant Staphylococcus aureus require contact precautions.
D. Droplet
Rationale: Clients who have streptococcal pharyngitis and other infections such as rubella and diphtheria
require droplet precautions.
52. A nurse is caring for a client who has hypernatremia and requires IV fluid therapy due to his NPO status. Which of
the following solutions should the nurse prepare to infuse for this client?
A. Lactated Ringer's
Rationale: This is an isotonic IV solution, which will not help correct the client's sodium elevation.
B. Dextrose 5% in 0.9% sodium chloride
Rationale: This is a hypertonic IV solution, which will not help correct the client's sodium elevation.
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AM RN CAPSTONE EXAM SUMMER 24
C. 0.45% sodium chloride
Rationale: A client who has an elevated sodium level and is NPO requires a hypotonic IV solution, such as
0.45% sodium chloride or 0.225% sodium chloride.
D. Dextrose 10% in water
Rationale: This is a hypertonic IV solution, which will not help correct the client's sodium elevation.
53. A charge nurse is anticipating the admission of four clients and planning their room assignments. Which of the
following clients should the nurse assign to the room closest to the nurses’ station?
A. A client who sustained a head injury and is having periods of confusion
Rationale: A client who sustained a head injury and is confused is at risk for seizures. The nurse should
place this client in a room near the nurses’ station so that he can be closely monitored to
prevent injury if a seizure occurs.
B. A client who reports a severe migraine headache
Rationale: A client who reports a severe migraine needs a quiet and dark room, as far from the nurses’
station as possible to reduce sensory stimuli.
C. A client who has a suspected diagnosis of tuberculosis (TB)
Rationale: A client who has a suspected diagnosis of TB requires airborne precautions. The location of the
room on the unit is not as important as the need for a private room with negative-pressure
airflow.
D. A client who has a history of atrial fibrillation and is on continuous ECG monitoring.
Rationale: This client can be placed in any available room on the unit because continuous ECG
monitoring can be done remotely and trained personnel observe the client's heart rhythm at all
times on the monitor screen.
54. A nurse is giving a presentation about client confidentiality to a group of newly licensed nurses. Which of the
following actions is an example of a violation of confidentiality?
A. Discussing a client’s surgical procedure with the nurse manager
Rationale: The nurse may disclose protected health information to a person or agency involved in the
client’s care.
B. Reporting laboratory findings to a member of the client’s family
Rationale: Confidentiality is the nondisclosure of information except to an authorized person, that is,
someone involved in the client’s care or someone the client has given permission for informing.
Reporting laboratory findings to a family member without the client’s permission violates client
confidentiality.
C. Notifying the provider of physical examination findings
Rationale:
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AM RN CAPSTONE EXAM SUMMER 24
The nurse may disclose protected health information to a person or agency involved in the
client’s care.
D. Identifying the client by name when making a referral for home health services
Rationale: The nurse may disclose protected health information to a person or agency involved in the
client’s care.
55. A nurse is receiving change-of-shift report for a group of assigned clients. The nurse anticipates which of the
following activities first in delivering client care using the nursing process?
A. Critically analyze client data to determine priorities.
Rationale: There is another activity the nurse should complete first.
B. Collect and organize client data.
Rationale: The steps in the nursing process include assessment, analysis/diagnosis, planning,
implementation and evaluation. The nurse should first collect client data, and then critically
analyze the data to determine the clients’ priorities. This is followed by the nurse planning
client-centered, measurable and realistic goals. The nurse implements care, which involves
putting the plan into action, followed by evaluation to determine the effectiveness of the
interventions.
C. Set client-centered, measurable and realistic goals.
Rationale: There is another activity the nurse should complete first.
D. Determine effectiveness of interventions.
Rationale: There is another activity the nurse should complete first.
56. A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound.
The nurse enters the room to check the client’s pulse. Which of the following actions should the nurse take?
A. Wear an N95 respirator mask.
Rationale: The nurse should wear an N95 respirator mask when caring for a client who requires airborne
precautions.
B. Wear sterile gloves.
Rationale: The nurse should wear sterile gloves when performing a sterile procedure.
C. Wear clean gloves.
Rationale: The nurse should wear clean gloves to prevent the transmission of MRSA.
D. Wear protective eyewear.
Rationale: The nurse should wear protective eyewear when there is a risk of splash contamination, such
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AM RN CAPSTONE EXAM SUMMER 24
as during a dressing change.
57. A charge nurse is planning a room assignment for a client who has a productive cough, a questionable chest
x-ray, and a positive Mantoux test. Room 208 is a private, negative-pressure airflow room; room 212 is a
semi-private, positive-pressure airflow room; 214 is a negative-pressure, semi-private room; and room 216 is a
private, positive-pressure airflow room. To which of the following rooms should the nurse assign the client?
A. 208
Rationale: A client who has or might have tuberculosis requires airborne precautions. That means a
private room with negative-pressure airflow. Room 208 is the only one of these options that fits
these requirements.
B. 212
Rationale: A client who has or might have tuberculosis requires airborne precautions. That means a
private room with negative-pressure airflow. In a semi-private room, such as 212, another client
would have exposure to the new client’s infectious airborne particles.
C. 214
Rationale: A client who has or might have tuberculosis requires airborne precautions. That means a
private room with negative-pressure airflow. In a semi-private room, such as 214, another client
would have exposure to the new client’s infectious airborne particles.
D. 216
Rationale: A client who has or might have tuberculosis requires a room that has negative-pressure airflow.
Room 216 has positive-pressure airflow.
58. A nurse in a long-term care facility is planning care for several clients. Which of the following activities should the
nurse delegate to the licensed practical nurse (LPN)?
A. Admission assessment of a new client
Rationale: Delegation of the admission assessment as part of the nursing process is not appropriate, as
this requires nursing judgment.
B. Scheduling a diagnostic study for a client
Rationale: The LPN can schedule a diagnostic study as this does not involve assessment or nursing
judgment as part of the nursing process.
C. Evaluating changes to a client's pressure ulcer
Rationale: Delegation of assessing changes to a pressure ulcer is not appropriate, as this requires
specialized knowledge and judgment as part of the nursing process.
D. Teaching a client insulin injection technique
Rationale: Delegation of teaching is not appropriate, as this requires evaluation as part of the nursing
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AM RN CAPSTONE EXAM SUMMER 24
process. A LPN can reinforce prior teaching.
59. A charge nurse is making client care assignments. Which of the following tasks should the nurse delegate to
assistive personnel (AP)? (Select all that apply.)
Answers cannot be displayed for this alternate item format.
Rationale: Bathe a client who had an amputation 2 days ago is correct. Bathing a stable client
postoperatively is a task the nurse may delegate to an AP because the task is routine and is safe
and predictable for a client who is stable.Assist a client to ambulate using a gait belt is correct.
Assisting a client to ambulate using a gait belt is a task the nurse may delegate to an AP because
the task is routine and does not require much scientific knowledge.Review a low-sodium diet for
a client who has hypertension is incorrect. Reviewing a low-sodium diet is a task the nurse may
not delegate to an AP because it involves teaching, which is a nursing function.Explain oral
hygiene to a client receiving chemotherapy is incorrect. Explaining oral hygiene to a client
receiving chemotherapy is a task the nurse may not delegate to an AP because it involves
teaching, which is a nursing function.Feed a client who had a stroke 3 months ago is correct.
Feeding a client who had a stroke 3 months ago is a task the nurse may delegate to an AP
because the task is routine and is safe and predictable for a client who is stable.
60. A nurse is removing personal protective equipment (PPE) after giving direct care to a client who requires isolation.
Which of the following PPE items should the nurse remove first?
A. Gown
Rationale: The nurse should remove the gown, which is likely to have some contamination, when
preparing to leave the client’s room; however, evidence-based practice indicates that another
type of PPE is the priority for removal.
B. Gloves
Rationale: According to evidence-based practice, the nurse should remove the most contaminated item,
the gloves, first.
C. Face shield
Rationale: The nurse should remove the face shield, which is likely to have some contamination, before
leaving the client’s room; however, evidence-based practice indicates that another type of PPE
is the priority for removal.
D. Mask
Rationale: The nurse should remove the mask, which is likely to have some contamination, at the doorway
of the client’s room; however, evidence-based practice indicates that another type of PPE is the
priority for removal.
61. A client receives a wrong medication. The nurse who made the medication error should take which of the following
actions first?
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AM RN CAPSTONE EXAM SUMMER 24
A. Call the client’s provider.
Rationale: The nurse will have to notify the client’s provider in case the client needs medical intervention
and to follow the facility’s protocol for such incidents; however, there is another action the nurse
should take first.
B. Assess the client.
Rationale: The first action the nurse should take using the nursing process is to assess the client. The
nurse must first determine whether or not the error has caused the client any harm and also
provide any relevant interventions.
C. Notify the nurse manager.
Rationale: The nurse will have to notify the nurse manager to follow the facility’s protocol for such
incidents; however, there is another action the nurse should take first.
D. Complete an incident report.
Rationale: The nurse will have to complete an incident report to follow the facility’s protocol for such
incidents and to give risk managers the opportunity to investigate and institute preventive
measures if necessary; however, there is another action the nurse should take first.
62. A nurse in a prenatal clinic is caring for a client who is pregnant and asks the nurse for her estimated date of birth
(EDB). The client's last menstrual period began on July 27. What is the client's EDB? (State the date in MMDD.
For example, July 27 is 0727)
0504
Correct Rationale: Using Nägele's rule, the nurse subtracts three months from the date of the last menstrual
period, then adds 7 days. July minus 3 months equals April. There are 30 days in April,
so 27 + 7 = May 4. The client's EDB is May 4, which would be written as 0504 in the
MMDD format.
InCorrect Rationale: Using Nägele's rule, the nurse subtracts three months from the date of the last
menstrual period, then adds 7 days. July minus 3 months equals April. There are 30
days in April, so 27 + 7 = May 4. The client's EDB is May 4, which would be written as
0504 in the MMDD format.
63. A nurse observes that a newborn has a pink trunk and head, bluish hands and feet, and flexed extremities 5 min
after delivery. He has a weak and slow cry, a heart rate of 130/min, and cries in response to suctioning. The nurse
should document what Apgar score for this infant?
8
Correct Rationale: Apgar scoring is an assessment of five areas of newborn well-being: respiratory effort,
heart rate, muscle tone, reflex irritability, and color. This newborn scores 2 each for heart
rate, muscle tone, and reflex irritability. The weak cry and acrocyanosis of the hands and
feet score 1 each, for a total of 8.
InCorrect Rationale: Apgar scoring is an assessment of five areas of newborn well-being: respiratory effort,
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AM RN CAPSTONE EXAM SUMMER 24
heart rate, muscle tone, reflex irritability, and color. This newborn scores 2 each for
heart rate, muscle tone, and reflex irritability. The weak cry and acrocyanosis of the
hands and feet score 1 each, for a total of 8.
64. Based on the information in the newborn's medical record, the nurse determines that the newborn is at risk for
developing which of the following complications?Complete the following sentence by using the list of options.
Answers cannot be displayed for this alternate item format.
Rationale: Dropdown 1Hypoglycemia is incorrect. The newborn has no risk factors for developing
hypoglycemia. Risk factors for hypoglycemia include hypothermia, preterm gestation, maternal
diabetes, low birth weight, small for gestational age, large for gestational age, and the presence of
respiratory distress. Additionally, the newborn is breastfeeding every 2 to 4 hr, which is within the
expected range.Jaundice is correct. A positive Coombs test indicates the presence of anti-A and
anti-B maternal antibodies within the newborn's blood. These antibodies will result in an
accelerated destruction of the newborn's type A blood cells. The by-product of red blood cell
hemolysis is bilirubin. The accelerated breakdown of the red blood cells can lead to excess
bilirubin accumulating within the newborn's skin, mucus membranes, and sclera, resulting in a
yellow discoloration known as jaundice. The nurse should continue to monitor the newborn's
bilirubin levels.Subgaleal hemorrhage is incorrect. The newborn has no risk factors or
manifestations of a subgaleal hemorrhage. A subgaleal hemorrhage can occur due to the shearing
forces associated with a vacuum extraction or forceps-assisted delivery. The trauma to the scalp
can result in bleeding within the subgaleal space. Manifestations include a boggy scalp, increasing
head circumference, and signs of blood loss, such as tachycardia and pallor.Dropdown 2Anemia
is correct. A positive Coombs test indicates the presence of anti-A and anti-B maternal antibodies
within the newborn's blood. These antibodies will cause an accelerated destruction of the
newborn's type A blood cells. The accelerated hemolysis can result in anemia.Neonatal
abstinence syndrome is incorrect. While the newborn's toxicology screen did demonstrate the
presence of cocaine and marijuana, neither of those substances cause neonatal abstinence
syndrome. Newborns who have been exposed to opioids while in utero are at risk for
demonstrating manifestations of opioid withdrawal after birth. Opioids include heroin, morphine,
methadone, meperidine, and oxycodone. Von Willebrand disease is incorrect. This condition is
a form of hemophilia, which results in prolonged bleeding related to a deficiency of one of the
clotting factors. The most common manifestation of this disorder is increased bleeding from the
mucus membranes. There is no information in the newborn's medical record or assessment that
indicates the newborn is at risk for developing this condition.
65. A nurse is preparing to assess a newborn who is postmature. Which of the following findings should the nurse
expect? (Select all that apply.)
Answers cannot be displayed for this alternate item format.
Rationale: Cracked, peeling skin is correct. Physical findings that indicate postmaturity in a newborn
(gestational age of greater than 42 weeks) include cracked, peeling skin.Positive Moro reflex is
correct. Reflexes that are present in a postmature newborn are the same as those that are
present in a mature newborn. These reflexes include a positive Moro reflex.Short, soft
fingernails is incorrect. Short, soft fingernails are not characteristic of the postmature newborn.
They appear long and are hard.
Abundant lanugo is incorrect. Abundant lanugo is seen in preterm (gestational age of less than 37 weeks) newborns.
Vernix in folds and creases is incorrect Vernix in the folds and creases is seen in mature, term newborns. Created on:09/05/2024 Page 34 Detailed Answer Key AM RN CAPSTONE EXAM SUMMER 24 66. A nurse is admitting a client who has a diagnosis of preterm labor. The nurse anticipates a prescription by the provider for which of the following medications? (Select all that apply.) Answers cannot be displayed for this alternate item format. Rationale: Prostaglandin E2 is incorrect. Prostaglandin E2 is used to stimulate cervical ripening and hasten the onset of labor.
Indomethacin is correct. Indomethacin is used to relax uterine smooth muscles and suppress uterine activity in clients who have a diagnosis of preterm labor.
Magnesium sulfate is correct. Magnesium sulfate is a tocolytic and stops contractions in clients experiencing preterm labor.
Methylergonovine is incorrect. Methylergonovine promotes uterine contractions to manage postpartum hemorrhage.Oxytocin is incorrect. Oxytocin is used to induce and augment labor. 67. A nurse is admitting a client who is at 37 weeks of gestation and has severe gestational hypertension. Which of the following actions should the nurse expect to implement? (Select all that apply.) Answers cannot be displayed for this alternate item format. Rationale: Administer magnesium sulfate IV is correct. Magnesium sulfate IV is given as a tocolytic medication for preterm labor to relax smooth muscle of the uterus and as a treatment for preeclampsia. The underlying pathophysiology of preeclampsia is vasospasm. The nurse should closely monitor the client for signs of magnesium toxicity, such as loss of patellar reflexes, respiratory depression, cardiac arrhythmias, cardiac arrest, urinary retention, and serum magnesium levels higher than 8 mEq/L.Provide a dark, quiet environment is correct. A dark, quiet environment helps to decrease CNS stimulation, which minimizes the risk of seizures. Assess respiratory status every 4 hr is incorrect. The nurse should monitor the client's respiratory status closely because the client is at risk for respiratory depression. During an infusion of magnesium sulfate, the nurse should monitor the respiratory rate every 5 min and every 15 min during maintenance infusion. Depending on the client's response to the medication, the provider will prescribe for the vital signs to be monitored every 30 to 60 min thereafter.Evaluate neurologic status every 8 hr is incorrect. The nurse should evaluate the client's level of consciousness every hour.Ensure that calcium gluconate is readily available is correct. Calcium gluconate is the antidote for magnesium sulfate and should be readily available when administering magnesium sulfate. The nurse should be prepared to administer the medication in response to manifestations of magnesium toxicity, such as depressed respirations, oliguria, sudden drop in BP, loss of deep-tendon reflexes, and fetal distress. 68. A nurse is caring for a client who is at 36 weeks of gestation and who has a suspected placenta previa. Which of the following findings support this diagnosis? A. Painless red vaginal bleeding Rationale: Placenta previa is a condition of pregnancy when the placenta implants in the lower part of the uterus, partly or completely obstructing the cervical os (outlet to the vagina). Bright red, painless vaginal bleeding occurs in the second and third trimester. B. Increasing abdominal pain with a nonrelaxed uterus Rationale: Abruptio placenta is separation of the placenta from the site of uterine implantation before Created on:09/05/2024 Page 35 Detailed Answer Key AM RN CAPSTONE EXAM SUMMER 24 delivery of the fetus. When the placenta separates prematurely, there is internal bleeding, which is painful, and the uterus is nonrelaxed or becomes rigid as the separation advances. C. Abdominal pain with scant red vaginal bleeding Rationale: Placenta previa involves minimal to severe bright red vaginal bleeding in the absence of abdominal pain. D. Intermittent abdominal pain following passage of bloody mucus Rationale: Intermittent abdominal pain following passage of bloody mucus is a description of normal labor. The passage of bloody mucus represents the loss of the cervical mucous plug, also referred to as the "bloody show." 69. A nurse is caring for an antepartum client whose laboratory findings indicate a negative rubella titer. Which of the following is the correct interpretation of this data? A. The client is not experiencing a rubella infection at this time. Rationale: A negative rubella titer indicates the client is susceptible to the rubella virus. It does not indicate the presence or absence of a rubella infection. B. The client is immune to the rubella virus. Rationale: A negative rubella titer indicates the client is susceptible to the rubella virus. C. The client requires a rubella vaccination at this time. Rationale: Rubella vaccination during pregnancy is contraindicated because of possible injury to the developing fetus. D. The client requires a rubella immunization following delivery. Rationale: A negative rubella titer indicates that the client is susceptible to the rubella virus and needs vaccination following delivery. Immunization during pregnancy is contraindicated because of possible injury to the developing fetus. Following rubella immunization, the client should be cautioned not to conceive for 1 month. 70. A nurse has accepted a position on a pediatric unit and is learning about psychosocial development. Place Erikson's stages of psychosocial development in order from birth to adolescence. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) E. Trust vs. mistrust A. Autonomy vs. shame and doubt D. Initiative vs. guilt B. Industry vs. inferiority C. Identity vs. role confusion Created on:09/05/2024 Page 36 Detailed Answer Key AM RN CAPSTONE EXAM SUMMER 24 71. A nurse is preparing to administer acetaminophen 10 mg/kg/dose to a child who weighs 28 lb. The amount available is acetaminophen 120 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) 5.3 mL Correct Rationale: Follow these steps for the Ratio and Proportion method of calculation:Step 1: What is the unit of measurement the nurse should calculate? kg Step 2: Set up an equation and solve for X. 2.2 lbClient's weight in lb
=
1 kgX kg2.2 lb28 lb
=
1 kgX kgX kg = 12.7272 kgStep 3: What is the unit of measurement the nurse should calculate? mg Step 4: Set up an equation and solve for X. X mg = Dose per kg × Client's weight in kgX mg = 10 mg × 12.7272 X mg = 127.2727 mgStep 5: What is the unit of measurement the nurse should calculate? mL Step 6: What is the dose the nurse should administer? Dose to administer = Desired 127.2727 mg Step 7: What is the dose available? Dose available = Have 120 mg Step 8: Should the nurse convert the units of measurement? No Step 9: What is the quantity of the dose available? 5 mL Step 10: Set up an equation and solve for X. HaveDesired
=
QuantityX120 mg127.2727
=
5 mLX mLX mL = 5.3030 mLStep 11: Round if necessary. 5.3030 = 5.3 Step 12: Reassess to determine whether the amount to give makes sense. If there are 120 mg/5 mL and the amount prescribed is 127 mg, it makes sense to administer acetaminophen 5.3 mL.Follow these steps for the Desired Over Have method of calculation:Step 1: What is the unit of measurement the nurse should calculate? kg Step 2: Set up an equation and solve for X. Client's weight in lb × 1 kgX kg =
2.2 lb28lb × 1 kgX kg
=
2.2lbX kg = 12.7272 kgStep 3: What is the unit of
measurement the nurse should calculate? mg Step 4: Set up an equation and solve for X.
X mg = Dose per kg × Client's weight in kgX mg = 10 mg
× 12.7272 X mg = 127.2727Step 5: What is the unit of measurement the
nurse should calculate? mL Step 6: What is the dose the nurse should administer? Dose
to administer = Desired 127.2727 Step 7: What is the dose available? Dose available =
Have 120 mg Step 8: Should the nurse convert the units of measurement? No Step 9:
What is the quantity of the dose available? 5 mL Step 10: Set up an equation and solve
for X. Desired × QuantityX =
Have127.2727mg × 5 mLX mL =
120mgX mL = 5.3030 mLStep 11: Round if necessary.
5.3030 = 5.3 mLStep 12: Reassess to determine whether the amount to give makes
sense. If there are 120 mg/5 mL and the amount prescribed is 127 mg, it makes sense to
administer acetaminophen 5.3 mL. Follow these steps for the Dimensional Analysis
method of calculation:Step 1: What is the unit of measurement the nurse should
calculate? (Place the unit of measure being calculated on the left side of the equation.)
X mL = Step 2: Determine the ratio that contains the same unit as the unit being
calculated. (Place the ratio on the right side of the equation, ensuring that the unit in the
numerator matches the unit being calculated.) 5 mLX mL =
120 mgStep 3: Place any remaining ratios that are relevant to the item on the right side of the equation, along with any needed conversion factors, to cancel out unwanted units of measurement. 5 mL10mg1 kg28 lbX mL =
×
×
×
120mg1 kg2.2 lb1 doseStep 4: Solve for X. X mL
= 5.3030 mL/doseStep 5: Round if necessary. 5.3030 = 5.3 mL/doseStep 6: Reassess to
determine whether the amount to give makes sense. If there are 120 mg/5 mL and the
amount prescribed is 127 mg, it makes sense to administer acetaminophen 5.3 mL.
InCorrect Rationale:
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AM RN CAPSTONE EXAM SUMMER 24
Follow these steps for the Ratio and Proportion method of calculation:Step 1:
What is the unit of measurement the nurse should calculate? kg Step 2: Set up an
equation and solve for X. 2.2 lbClient's weight in lb
=
1 kgX kg2.2 lb28 lb
=
1 kgX kgX kg = 12.7272 kgStep 3: What is the unit of measurement the nurse should calculate? mg Step 4: Set up an equation and solve for X. X mg = Dose per kg × Client's weight in kgX mg = 10 mg × 12.7272 X mg = 127.2727 mgStep 5: What is the unit of measurement the nurse should calculate? mL Step 6: What is the dose the nurse should administer? Dose to administer = Desired 127.2727 mg Step 7: What is the dose available? Dose available = Have 120 mg Step 8: Should the nurse convert the units of measurement? No Step 9: What is the quantity of the dose available? 5 mL Step 10: Set up an equation and solve for X. HaveDesired
=
QuantityX120 mg127.2727
=
5 mLX mLX mL = 5.3030 mLStep 11: Round if necessary. 5.3030 = 5.3 Step 12: Reassess to determine whether the amount to give makes sense. If there are 120 mg/5 mL and the amount prescribed is 127 mg, it makes sense to administer acetaminophen 5.3 mL.Follow these steps for the Desired Over Have method of calculation:Step 1: What is the unit of measurement the nurse should calculate? kg Step 2: Set up an equation and solve for X. Client's weight in lb × 1 kgX kg =
2.2 lb28lb × 1
kgX kg =
2.2lbX kg = 12.7272 kgStep 3:
What is the unit of measurement the nurse should calculate? mg Step 4: Set up an
equation and solve for X. X mg = Dose per kg × Client's weight in
kgX mg = 10 mg × 12.7272 X mg = 127.2727Step 5: What is the
unit of measurement the nurse should calculate? mL Step 6: What is the dose the
nurse should administer? Dose to administer = Desired 127.2727 Step 7: What is the
dose available? Dose available = Have 120 mg Step 8: Should the nurse convert the
units of measurement? No Step 9: What is the quantity of the dose available? 5 mL
Step 10: Set up an equation and solve for X. Desired ×
QuantityX =
Have127.2727mg
× 5 mLX mL =
120mgX mL =
5.3030 mLStep 11: Round if necessary. 5.3030 = 5.3 mLStep 12: Reassess to
determine whether the amount to give makes sense. If there are 120 mg/5 mL and the
amount prescribed is 127 mg, it makes sense to administer acetaminophen 5.3 mL.
Follow these steps for the Dimensional Analysis method of calculation:Step 1:
What is the unit of measurement the nurse should calculate? (Place the unit of
measure being calculated on the left side of the equation.) X mL = Step 2:
Determine the ratio that contains the same unit as the unit being calculated. (Place the
ratio on the right side of the equation, ensuring that the unit in the numerator matches
the unit being calculated.) 5 mLX mL =
120 mgStep 3: Place any remaining ratios that are relevant to the item on the right side of the equation, along with any needed conversion factors, to cancel out unwanted units of measurement. 5 mL10mg1 kg28 lbX mL =
×
×
×
120mg1
kg2.2 lb1 doseStep 4: Solve for X. X mL = 5.3030
mL/doseStep 5: Round if necessary. 5.3030 = 5.3 mL/doseStep 6: Reassess to
determine whether the amount to give makes sense. If there are 120 mg/5 mL and the
amount prescribed is 127 mg, it makes sense to administer acetaminophen 5.3 mL.
72. Complete the following sentence by using the list of options.
Answers cannot be displayed for this alternate item format.
Rationale:
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Dropdown 1Pulmonary embolism is correct. Immobility from traction decreases venous return
and causes pooling of blood, which increases the risk of clot formation. The child is receiving
traction therapy for management of femur fracture and is experiencing a change in respiratory
status with their respirations being slightly labored. These findings put the child at great risk for
developing an embolus. Fecal impaction is incorrect. The child has limited mobility from
traction, which increases the child's risk for developing constipation and fecal impaction. However,
the child's assessment findings indicate a soft-formed bowel movement 2 days ago; therefore, this
is not a high risk. Paralytic ileus is incorrect. While a child who is immobile has an increased
chance of a paralytic ileus, this is not the highest risk. The child has active bowel sounds and had
a bowel movement two days ago. Hypotension is incorrect. The effects of immobility can cause
an increase in blood pressure; therefore, this is not a great risk for the child. Renal calculi are
incorrect. Immobility increases urine stasis and possibly bladder distention and increases the risk
for calculi formation; however, the child is having urinary output. Therefore, this is not a great risk
for the client. Dropdown 2Oxygen saturation level is correct. The child's oxygen saturation level
has decreased, which indicates hypoxia. This finding can be related to pulmonary embolism.
Blood pressure is incorrect. The child's blood pressure is within the expected reference range for
a school-age child.Bowel sounds is incorrect. The child has hypoactive active bowel sounds and
had a bowel movement two days ago. Stool characteristics is incorrect. The child had a soft
formed stool 2 days ago; therefore, there is no indication that the child is at risk for impaction.
Urine characteristics is incorrect. The child's genitourinary assessment revealed no unexpected
findings. The child was able to void 200 mL of clear, yellow urine, which is an expected finding.
73. A child is admitted with a suspected diagnosis of Wilms' tumor. The nurse should place a sign with which of the
following warnings over the child's bed?
A. Do not palpate abdomen.
Rationale: Wilms' tumor is a neoplasm of the kidney (nephroblastoma). This tumor is encapsulated, and
palpation can cause it to rupture, which would allow seeding of the tumor into the pelvic cavity.
B. No venipuncture or blood pressure in left arm
Rationale: There is no contraindication for venipuncture or obtaining blood pressure in either of the child's
arms.
C. Contact precautions
Rationale: There is no indication to place the child on contact precautions.
D. Collect all urine.
Rationale: There is no indication to collect urine for a 24-hr urine specimen.
74. A nurse is providing discharge teaching about nutrition to the parents of a child who has cystic fibrosis (CF). Which
of the following responses by the parents indicates an understanding of the teaching?
A. "We will give our child pancreatic enzymes with snacks and meals."
Rationale: CF interferes with the availability of pancreatic enzymes necessary for digestion and absorption
of nutrients. Therefore, pancreatic enzymes must be taken with all meals and snacks.
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B. "We will restrict the amount of salt in our child's food."
Rationale: CF does not cause a child's sodium requirements to decrease. Adequate sodium is required for
electrolyte balance, and at times when the child loses excessive fluids due to diaphoresis,
additional sodium might be required.
C. "I will limit my child's fluid intake."
Rationale: Fluids should not be restricted. Dehydration due to inadequate fluid intake can aggravate the
excessive buildup of tenacious respiratory mucus associated with CF.
D. "I will prepare low-fat meals with limited protein for my child."
Rationale: A diet that is high in calories and protein, and unrestricted in fats and salt, is typically
recommended to meet the nutritional needs of the child who has CF.
75. A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take?
A. Attempt to stop the seizure.
Rationale: Attempting to stop the seizure can cause further injury to the child.
B. Restrain the child's arms.
Rationale: Restraining the child's arms can cause further injury to the child.
C. Use a padded tongue blade.
Rationale: Using a padded tongue blade can cause further injury to the child.
D. Position the child laterally.
Rationale: Positioning the child laterally facilitates airway patency.
76. A nurse is caring for a child who has a tracheostomy. After suctioning the tracheostomy, the nurse should use
which of the following findings to determine that the procedure was effective?
A. Increased respiratory rate
Rationale: A rise in respiratory effort indicates that there is mucus partially obstructing the airway and
suctioning did not clear it.
B. Stable oxygen saturation
Rationale: Oxygen saturation can drop during suctioning. If it was below the acceptable range prior to
suctioning, the procedure was not effective.
C. Clear breath sounds
Rationale: Clear breath sounds indicate that there are no remaining secretions obstructing or potentially
obstructing the client's airway.
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D. Brisk capillary refill
Rationale: Capillary refill is an indication of the quality of peripheral circulation, not oxygenation.
77. Which of the following is the most characteristic feature of neuroleptic malignant syndrome (NMS)?
A. Hyperthermia
Rationale: Hyperthermia, or elevated body temperature, is a hallmark symptom of neuroleptic malignant
syndrome, along with muscle rigidity and autonomic dysfunction.
B. Hyperactivity
Rationale: Hyperactivity is not characteristic of NMS; instead, patients typically exhibit muscle rigidity and
altered mental status.
C. Bradycardia
Rationale: Bradycardia is not a common feature of NMS; patients often experience tachycardia due to
autonomic dysfunction.
D. Hypotension
Rationale: Hypotension is less characteristic of NMS; hypertension and tachycardia are more commonly
observed.
78. Which of the following best describes a psychiatric advance directive (PAD)?
A. A legal document that allows patients to specify their preferences for treatment in the event they become
unable to make decisions.
Rationale: This is the correct description of a psychiatric advance directive (PAD). It is a legal document
that allows individuals to outline their treatment preferences and appoint a healthcare proxy in
case they are unable to make decisions due to a mental health crisis.
B. A document that requires patients to follow a specific treatment plan designed by their physician.
Rationale: This is incorrect because a PAD is not about enforcing a treatment plan designed by a
physician, but rather about the patient's autonomy to outline their own treatment preferences.
C. A form used to request financial assistance for psychiatric treatment.
Rationale: This is incorrect because a PAD is not related to financial assistance but focuses on treatment
preferences and decision-making authority during a mental health crisis.
D. A medical order that healthcare providers must follow without any modifications.
Rationale: This is incorrect because a PAD provides guidance on a patient's preferences, but it may not
always be followed without modification, especially in emergency situations where clinical
judgment is required.
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79. Which of the following is a primary indication for electroconvulsive therapy (ECT)?
A. Schizophrenia
Rationale: While ECT can be used in some cases of schizophrenia, it is not the primary indication.
B. Severe major depressive disorder
Rationale: ECT is most commonly used for severe major depressive disorder, especially when other
treatments have failed.
C. Generalized anxiety disorder
Rationale: ECT is not typically used to treat generalized anxiety disorder.
D. Obsessive-compulsive disorder
Rationale: ECT is not a first-line treatment for obsessive-compulsive disorder.
80. A nurse is educating a client who is prescribed clozapine. Which of the following findings should the nurse identify
as consistent with agranulocytosis and instruct the client to monitor?
A. Increased anxiety and suicidal ideations
Rationale: The nurse should identify that increased anxiety and suicidal ideations are findings associated
with activation syndrome.
B. Sore throat and muscle aches
Rationale: The nurse should identify that flu-like manifestations, such as a sore throat and muscle aches,
are findings associated with agranulocytosis, a potentially life-threatening adverse effect.
C. Respiratory depression and a comatose state
Rationale: The nurse should identify that respiratory depression and a comatose state are findings
associated with severe lithium toxicity.
D. Severe restlessness
Rationale: The nurse should identify that severe restlessness that is not relieved by movement is a finding
associated with akathisia.
81. A nurse is reviewing abnormal laboratory values for four clients who have schizophrenia and take clozapine. For
which of the following clients should the nurse withhold the medication and notify the provider immediately to have
clozapine therapy discontinued?
A. A client who has a WBC of 2,900 cells/mm3
Rationale: A white blood cell count of 2,900 cells/mm3 is below the normal reference range of 5000 to
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AM RN CAPSTONE EXAM SUMMER 24
10000 cells/mm3 . The client who takes clozapine is at risk for agranulocytosis; therefore, a
client who has a WBC of less than 3000 mm3 should have clozapine withheld and treatment
stopped until the WBC returns to normal. Clozapine should be permanently stopped if a
client’s WBC falls below 2000 mm3.
B. A client who has a hematocrit of 55%
Rationale: A hematocrit of 55% is above the recommended reference range of 37% to 47% for females
and 42% to 52% for males, but is not a contraindication for clozapine therapy.
C. A client who has a serum potassium of 3.3 mEq/L
Rationale: A serum potassium of 3.3 mEq/L is below the recommended reference range of 3.5 to 5.0
mEq/L . A low or high potassium level should be reported, but is not a contraindication for
clozapine therapy.
D. A client who has a BUN of 22 mg/dL
Rationale: A BUN of 22 mg/dL is above the recommended reference range to 10 to 20 mg/dL and should
be reported, but is not a contraindication for clozapine therapy.
82. Which of the following components is NOT included in the Mini Mental Status Exam (MMSE)?
A. Orientation to time and place
Rationale: Orientation to time and place is a key component of the MMSE used to assess cognitive
function.
B. Memory recall
Rationale: Memory recall is included in the MMSE to evaluate short-term memory function.
C. Language comprehension and production
Rationale: Language comprehension and production are assessed in the MMSE to evaluate
communication abilities.
D. Assessment of cranial nerves
Rationale: Assessment of cranial nerves is not included in the MMSE. The MMSE focuses on cognitive
functions rather than neurological examinations.
83. Which of the following statements is true regarding Electroconvulsive Therapy (ECT)?
A. ECT is primarily used as a first-line treatment for depression.
Rationale: ECT is typically used when other treatments, such as medications and psychotherapy, have
failed or are not suitable.
B. ECT causes permanent memory loss in all patients.
Rationale:
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While ECT can cause temporary memory loss, permanent memory loss is rare and usually
limited to events close to the treatment period.
C. ECT involves the application of electrical currents to the brain to induce seizures.
Rationale: This is the correct mechanism of action for ECT, which involves passing electrical currents
through the brain to intentionally trigger a brief seizure.
D. ECT is a painful procedure requiring no anesthesia.
Rationale: ECT is performed under general anesthesia, ensuring that the patient does not feel pain during
the procedure.
84. What is the primary characteristic of voluntary admission in a psychiatric facility?
A. The patient is admitted without their consent.
Rationale: This describes involuntary admission, not voluntary admission.
B. The patient has the right to request discharge at any time.
Rationale: In voluntary admission, patients have the right to request discharge unless they are deemed a
threat to themselves or others.
C. The patient must stay for a mandatory 72-hour observation period.
Rationale: This requirement is often associated with involuntary admission or specific state laws, not
voluntary admission.
D. The patient is required to have a court order for admission.
Rationale: Court orders are typically associated with involuntary admission, not voluntary admission.
85. Which of the following best describes the phenomenon known as 'sundowning' in patients with dementia?
A. A. An increase in confusion and agitation occurring in the late afternoon and evening.
Rationale: Correct. Sundowning refers to an increase in confusion and agitation that typically occurs in the
late afternoon and evening in patients with dementia.
B. B. A sudden improvement in cognitive function and mood in the early morning hours.
Rationale: Incorrect. Sundowning is associated with increased confusion and agitation, not an
improvement in cognitive function and mood.
C. C. An improvement in memory recall and orientation at night.
Rationale: Incorrect. Sundowning involves worsening symptoms of confusion and agitation, not
improvement.
D. D. A consistent level of cognitive function throughout the day with no significant changes.
Rationale:
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AM RN CAPSTONE EXAM SUMMER 24
Incorrect. Sundowning specifically refers to a noticeable change in behavior and cognitive
function, typically worsening in the late afternoon and evening.
86. A nurse is conducting a psychoeducation group about the etiology of eating disorders. Which of the following
statements should the nurse include?
A. "A specific gene has been identified as the primary cause of eating disorders."
Rationale: Although genetics is believed to play a role, there are multiple factors that contribute to the
cause of eating disorders.
B. "Western cultural values are the primary cause of eating disorders."
Rationale: Although culture is an influential factor in the cause of an eating disorder, there are multiple
factors that contribute to their etiology.
C. "There is a mix of biological and psychosocial determinants that contribute to the development of eating
disorders."
Rationale: The cause of an eating disorder is multifactorial and best explained by the diathesis-stress
model, which poses that there are environmental and psychosocial factors, as well as biological
and genetic factors that contribute to the development of an eating disorder.
D. "Childhood trauma is the primary contributor to the development of an eating disorder."
Rationale: Although childhood trauma has been correlated with the development of eating disorders, this
has not been identified as the primary cause of eating disorders.
87. A nurse is caring for an adolescent female who has an eating disorder. The client is 162.6 cm (64 in) tall and
weighs 38.56 kg (85 lb). Upon assessment, which of the following manifestations should the nurse expect? (Select
all that apply.)
Answers cannot be displayed for this alternate item format.
Rationale: Amenorrhea is correct. A client who has anorexia nervosa and has had significant weight loss will
commonly experience amenorrhea, or cessation of menses.Verbalized desire to gain weight is
incorrect. A client who has anorexia nervosa sees herself as overweight and often has fear of
gaining weight.Altered body image is correct. A client who has anorexia nervosa will commonly
view her body as overweight no matter how much weight is lost.Hyperactivity is correct. A client
who has anorexia nervosa will commonly engage in excessive exercising to prevent weight gain.
Bradycardia is correct. A client who has anorexia nervosa can experience cardiac abnormalities,
such as bradycardia and hypotension.
88. A nurse in a mental health clinic is assessing a client who was brought in by her adult daughter stating that her
mother has not been able to leave her home for weeks because she is afraid to be outdoors alone. The nurse
should anticipate planning care for managing which of the following phobias?
A. Xenophobia
Rationale:
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Xenophobia is a fear of strangers.
B. Acrophobia
Rationale: Acrophobia is a fear of heights.
C. Mysophobia
Rationale: Mysophobia is a fear of dirt or germs.
D. Agoraphobia
Rationale: Agoraphobia is an irrational fear about being in places or circumstances where the client would
not have help in the event of panic or other forms of anxiety. Fear of being alone outdoors is a
common example.
89. A nurse is caring for a client who was admitted with delirium tremens five days ago. The client seeks permission
from the nurse before performing activities of daily living. This behavior indicates which of the following findings to
the nurse?
A. The client is ready for discharge.
Rationale: Seeking permission to complete activities of daily living does not indicate the client is ready for
discharge. The client should be able to function independently prior to discharge.
B. The client may be having a recurrence of delirium tremens.
Rationale: Seeking permission to complete activities of daily living is not a manifestation of delirium
tremens, and does not indicate a recurrence may be occurring.
C. The client is able to function independently.
Rationale: Seeking permission to complete activities does not indicate the client is able to function
independently. Independence is exhibited by an ability to make decisions without guidance or
input from others.
D. The client is exhibiting dependency.
Rationale: Seeking permission for simple tasks indicates dependent functioning.
90. Which of the following is an example of a negative symptom of schizophrenia?
A. Hallucinations
Rationale: Hallucinations are considered a positive symptom of schizophrenia, as they involve the addition
of unusual experiences such as hearing voices.
B. Delusions
Rationale: Delusions are another positive symptom of schizophrenia, characterized by strong, false beliefs
that are resistant to reasoning.
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C. Avolition
Rationale: Avolition is a negative symptom of schizophrenia, characterized by a lack of motivation to
initiate and perform self-directed purposeful activities.
D. Disorganized speech
Rationale: Disorganized speech is considered a positive symptom, as it reflects disorganized thinking and
is an addition to normal speech patterns.
91. Which of the following best describes Dissociative Identity Disorder (DID), commonly known as multiple
personality disorder?
A. A condition where an individual feigns multiple personalities for attention.
Rationale: This is incorrect as DID is not about feigning personalities but involves distinct identity states.
B. A disorder characterized by the presence of two or more distinct personality states or identities that control
an individual's behavior at different times.
Rationale: This is correct as DID involves the presence of two or more distinct identities that take control
of the person's behavior.
C. A condition where a person has mood swings between extreme happiness and deep depression.
Rationale: This is incorrect as this description fits Bipolar Disorder, not DID.
D. A type of schizophrenia where an individual hears multiple voices in their head.
Rationale: This is incorrect as DID is distinct from schizophrenia, which involves symptoms like
hallucinations but not multiple distinct identities.
92. Which of the following is the most common first symptom of alcohol withdrawal?
A. Seizures
Rationale: Seizures can occur during alcohol withdrawal, but they are not typically the first symptom.
B. Hallucinations
Rationale: Hallucinations can occur, but they are not the most common initial symptom of alcohol
withdrawal.
C. Tremors
Rationale: Tremors, or 'the shakes,' are often the first and most common symptom of alcohol withdrawal.
D. Delirium Tremens
Rationale: Delirium Tremens is a severe form of alcohol withdrawal but typically occurs later, not as an
initial symptom.
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AM RN CAPSTONE EXAM SUMMER 24
93. A nurse is caring for a client who was involved in heavy combat and observed war casualties. The nurse should
suspect that the client is suffering from posttraumatic stress disorder (PTSD) if the client makes which of the
following statements?
A. "I check any room I enter because the enemy is still after me and could be hiding anywhere."
Rationale: This client is making a paranoid statement, something more typical of a client who has
persecutory delusions. This statement is not characteristic of a client who has PTSD.
B. "My child was born with a birth defect due to an exposure I had overseas."
Rationale: This statement is not characteristic of a client who has PTSD.
C. "I killed four enemy soldiers with my bare hands and saved my entire battalion."
Rationale: This client is making a grandiose statement, something more typical of a client who has bipolar
disorder in the manic phase. This statement is not characteristic of a client who has PTSD.
D. "In my dreams, all I can see are the wounded reaching out and trying to grab me."
Rationale: Many clients who have PTSD repeatedly re-experience the ordeal in the form of flashback
episodes, memories, nightmares, or frightening thoughts, especially when they are exposed to
events or objects reminiscent of the trauma. This client's statement about haunting dreams is
typical of a client who has PTSD.
94. A nurse is caring for a client who has been hospitalized for treatment of bipolar disorder and will be discharged
with a prescription for lithium. The nurse's discharge teaching should include information cautioning against which
of the following factors that may cause lithium toxicity?
A. Experiencing diarrhea
Rationale: Lithium is used to treat the manic stage of bipolar disorder. Toxicity occurs when the level of
lithium in the blood becomes too high. A low sodium level, or factors which result in a low
sodium level, (such as dehydration, diarrhea, sweating, excess exercise in hot weather, diuretic
use, a low sodium diet) increases the lithium level because the kidney processes sodium and
lithium in the same way. If sodium levels fall, the body conserves lithium, causing lithium levels
to rise.
B. Exercising moderately
Rationale: Moderate exercise should not lead to lithium toxicity.
C. Increasing sodium intake
Rationale: Increasing sodium intake will lead to excretion of lithium and a drop in the lithium level.
D. Drinking green tea
Rationale: Both green and black tea can lower lithium levels, making it less effective.
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AM RN CAPSTONE EXAM SUMMER 24
95. A nurse is caring for a client who is dying. The client says, "My mother died in the hospital, but I did not get there
before she died." Which of the following statements should the nurse make?
A. "We will call your family in time for them to get here."
Rationale: The nurse dismisses the client’s concerns and gives false reassurance.
B. "I wonder if you are fearful of dying alone."
Rationale: The nurse is verbalizing the client’s implied concerns and seeks to validate if this is the client’s
concern.
C. "I will make sure a staff member is in your room at all times."
Rationale: The nurse assumes she understands the client’s concerns and is promising something that
may not be possible.
D. "I will tell your family of your concern so that they can be here."
Rationale: The nurse assumes she understands the client’s concerns and has a plan which may violate
client confidentiality.
96. A nurse is caring for a client who has anorexia nervosa and overexercises to avoid gaining weight. Which of the
following nursing actions should the nurse take?
A. Praise the client for looking at herself in a mirror.
Rationale: A client who has anorexia nervosa monitors weight and appearance excessively, but does not
have a proper body image. The nurse should avoid sounding too complimentary of the client’s
appearance because it may reinforce negative thoughts.
B. Ask the client to agree to talk to a nurse whenever she feels the urge to exercise.
Rationale: To promote effectiveness of treatment, the nurse should implement actions which establish
trust and partnership with the client. This action should help the client view the nurse as a
partner in treatment.
C. Reprimand the client about the potential damage that has occurred due to overexercising her body.
Rationale: The nurse should focus teaching on healthy eating and addressing wrong thoughts about
weight gain. Confronting the client is not likely to be effective until the client can resolve the
issues that underlie the behaviors associated with anorexia nervosa.
D. Restrict the client from being weighed.
Rationale: During therapy, the nurse should weigh the client daily for the first week, then three times a
week. A client who has anorexia nervosa is likely to want to avoid weighing or seeing the
weight.
97. A nurse is preparing to administer amoxicillin 100 mg PO every 8 hr to a toddler who weighs 20 kg. The
recommended dosage range is 20 to 25 mg/kg/day. Which of the following actions by the nurse is appropriate?
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AM RN CAPSTONE EXAM SUMMER 24
A. The nurse administers the prescribed dosage.
Rationale: It is the nurse's responsibility to verify the correct dosage, withhold the medication if there is an
error, and notify the provider.
B. The nurse determines the prescription is above the recommended dosage range.
Rationale: The prescribed dose is less than the recommended dose, which is 400 to 500 mg/day (20 mg x
20 kg = 400 mg/day; 25 mg x 20 kg = 500 mg/day). The prescribed dose is 100 mg every 8 hr
(100 mg x 3 doses daily = 300 mg/day).
C. The nurse contacts the pharmacist to adjust the prescribed dosage.
Rationale: A nurse should contact the provider when there is a difference between the recommended and
prescribed dose. The provider must revise the order to ensure safe dosage.
D. The nurse determines the prescription is insufficient to achieve the desired effect.
Rationale: The dose is below the recommended range: 20 kg x 20 mg = 400 mg/kg/day; 20 kg x 25 mg =
500 mg/kg/day. Based on the toddler's weight, it would be safe for the client to receive 400 to
500 mg/day of amoxicillin. The toddler is receiving a total of 300 mg/day (100 mg x 3 doses
daily). The nurse should notify the provider as the prescribed dose is below the recommended
dosage range.
98. A nurse is calculating the intake of a client during the past 9 hr. The client's intake includes lactated Ringer's IV at
150 mL/hr, cefazolin 2 g IV intermittent bolus in 100 mL of 0.9% sodium chloride, two units of packed RBCs of 275
mL and 250 mL; two IV bolus infusions of 250 mL of 0.9% sodium chloride, famotidine 20 mg IV intermittent bolus
in 50 mL of 0.9% sodium chloride. How many mL of intake should the nurse record?
2525 mL
Correct Rationale: Lactated Ringer's 150 mL x 9 hr = 1,350 mL cefazolin = 100 mL packed RBCs 275 mL +
250 mL = 525 mL 0.9% sodium chloride bolus 250 mL + 250 mL = 500 ml famotidine = 50
mL
Total intake = 2,525 mL
InCorrect Rationale: Lactated Ringer's 150 mL x 9 hr = 1,350 mL cefazolin = 100 mL packed RBCs 275 mL
+ 250 mL = 525 mL 0.9% sodium chloride bolus 250 mL + 250 mL = 500 ml famotidine
= 50 mL
Total intake = 2,525 mL
99. A nurse is caring for a client who has an NG tube set to low intermittent suction. The nurse irrigates the NG tube
twice with 30 mL of normal saline solution during his shift. At the end of the shift, the NG canister contains 475 mL.
What amount of NG drainage should the nurse record? (Round the answer to the nearest whole number. Use a
leading zero if it applies. Do not use a trailing zero.)
415 mL
Correct Rationale: The nurse should measure the total drainage in the NG collection device and subtract the
amount of irrigant in order to obtain the true amount of drainage. STEP 1: What is the
unit of measurement the nurse should calculate? mL
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AM RN CAPSTONE EXAM SUMMER 24
STEP 2: What is the amount of drainage in the NG canister? Quantity = 475 mg
STEP 3: What is the amount of irrigation used? Irrigation = 60 mL (30 x 2)
STEP 4: Should the nurse convert the units of measurement? No
STEP 5: Set up an equation and solve for X.
Quantity - Irrigation = X
475 – 60 = X
415 = X
STEP 7: Round if necessary.
STEP 8: Reassess to determine whether the amount to administer makes sense. If there
is 475 mL of drainage in the canister and the nurse irrigated the NG tube twice with 30
mL each time, it makes sense that subtracting the irrigation amount from the amount in
the canister determines the true amount of drainage (475 mL – 60 mL = 415 mL). The
nurse should document 715 mL of NG drainage in the client's I&O record.
InCorrect Rationale: The nurse should measure the total drainage in the NG collection device and subtract
the amount of irrigant in order to obtain the true amount of drainage. STEP 1: What is
the unit of measurement the nurse should calculate? mL
STEP 2: What is the amount of drainage in the NG canister? Quantity = 475 mg
STEP 3: What is the amount of irrigation used? Irrigation = 60 mL (30 x 2)
STEP 4: Should the nurse convert the units of measurement? No
STEP 5: Set up an equation and solve for X.
Quantity - Irrigation = X
475 – 60 = X
415 = X
STEP 7: Round if necessary.
STEP 8: Reassess to determine whether the amount to administer makes sense. If
there is 475 mL of drainage in the canister and the nurse irrigated the NG tube twice
with 30 mL each time, it makes sense that subtracting the irrigation amount from the
amount in the canister determines the true amount of drainage (475 mL – 60 mL = 415
mL). The nurse should document 715 mL of NG drainage in the client's I&O record.
100.A graduate nurse who has been recently hired at a local hospital is completing an application for a nursing
license. Which of the following information is a requirement for the nurse during the initial licensure process?
Answers cannot be displayed for this alternate item format.
Rationale: Substance misuse within the last 5 years is a requirement during the initial licensure process for a
graduate nurse.Nursing specialty, such a medical-surgical nursing or pediatrics, is not a
requirement during the initial licensure process for a graduate nurse.Verification of graduation
from a nursing program is a requirement during the initial licensure process for a graduate
nurse.Passing the NCLEX examination is a requirement during the initial licensure process for a
graduate nurse.Place of employment for the nurse is not a requirement during the initial licensure
process for a graduate nurse.
Created on:09/05/2024
Page 51
Time (hr)250 mLX mL/hr =
6 hrX mL/hr = 41.6666 mL/hrStep 6: Round if Created on:09/05/2024 Page 18 Detailed Answer Key AM RN CAPSTONE EXAM SUMMER 24 ortion or Desired Over Have method of calculation:Step 1: What is the unit of measurement the nurse should calculate? mL/hr Step 2: What is the volume the nurse should infuse? 250 mL Step 3: What is the total infusion time? 6 hr Step 4: Should the nurse convert the units of measurement? No Step 5: Set up an equation and solve for X. Volume (mL)X mL/hr =
Time (hr)250 mLX mL/hr =
6 hrX mL/hr = 41.6666 mL/hrStep 6: Round if necessary. 41.6666 = 42 mL/hrStep 7: Reassess to determine whether the amount to administer makes sense. If the prescription reads 1 g potassium phosphate in D5W 250 mL IV to infuse over 6 hr, it makes sense to administer 42 mL/hr. The nurse should set the IV pump to deliver 1 g potassium phosphate in D5W 250 mL IV at 42 mL/hr. Follow these steps to calculate the infusion rate using the Dimensional Analysis method of calculation:Step 1: What is the unit of measurement the nurse should calculate? (Place the unit of measure being calculated on the left side of the equation.) X mL/hr = Step 2: Determine the ratio that contains the same unit as the unit being calculated. (Place the ratio on the right side of the equation, ensuring that the unit in the numerator matches the unit being calculated.) 250 mLX mL/hr =
6 hrStep 3: Place any remaining ratios that are relevant to the item on the right side of the equation, along with any needed conversion factors, to cancel out unwanted units of measurement. 250 mLX mL/hr =
6 hrStep 4: Solve for X. X mL/hr = 41.6666 mL/hrStep 5: Round if necessary. 41.6666 = 42 mL/hrStep 6: Reassess to determine whether the amount to administer makes sense. If the prescription reads 1 g potassium phosphate in D5W 250 mL IV to infuse over 6 hr, it makes sense to administer 42 mL/hr. The nurse should set the IV pump to deliver 1 g potassium phosphate in D5W 250 mL IV at 42 mL/hr. InCorrect Rationale: Follow these steps to calculate the infusion rate using the Ratio and Proportion or Desired Over Have method of calculation:Step 1: What is the unit of measurement the nurse should calculate? mL/hr Step 2: What is the volume the nurse should infuse? 250 mL Step 3: What is the total infusion time? 6 hr Step 4: Should the nurse convert the units of measurement? No Step 5: Set up an equation and solve for X. Volume (mL)X mL/hr =
Time (hr)250 mLX mL/hr =
6 hrX mL/hr = 41.6666 mL/hrStep 6: Round if necessary. 41.6666 = 42 mL/hrStep 7: Reassess to determine whether the amount to administer makes sense. If the prescription reads 1 g potassium phosphate in D5W 250 mL IV to infuse over 6 hr, it makes sense to administer 42 mL/hr. The nurse should set the IV pump to deliver 1 g potassium phosphate in D5W 250 mL IV at 42 mL/hr. Follow these steps to calculate the infusion rate using the Dimensional Analysis method of calculation:Step 1: What is the unit of measurement the nurse should calculate? (Place the unit of measure being calculated on the left side of the equation.) X mL/hr = Step 2: Determine the ratio that contains the same unit as the unit being calculated. (Place the ratio on the right side of the equation, ensuring that the unit in the numerator matches the unit being calculated.) 250 mLX mL/hr =
6 hrStep 3: Place any remaining ratios that are relevant to the item on the right side of the equation, along with any needed conversion factors, to cancel out unwanted units of measurement. 250 mLX mL/hr =
6 hrStep 4: Solve for X. X mL/hr = 41.6666 mL/hrStep 5: Round if necessary. 41.6666 = 42 mL/hrStep 6: Reassess to determine whether the amount to administer makes sense. If the prescription reads 1 g potassium phosphate in D5W 250 mL IV to infuse over 6 hr, it makes sense to administer 42 mL/hr. The nurse should set the IV pump to deliver 1 g potassium phosphate in D5W 250 mL IV at 42 mL/hr. 44. A nurse is preparing to start an IV infusion of lactated Ringer's for a client who sustained a burn injury. The client is prescribed 5,200 mL of fluid over the first 24 hr. How many mL/hr should the nurse set the pump to infuse for the Created on:09/05/2024 Page 19 Detailed Answer Key AM RN CAPSTONE EXAM SUMMER 24 first 8 hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) 325 ml/hr Correct Rationale: Follow these steps to calculate the infusion rate using the Ratio and Proportion or Desired Over Have method of calculation:The nurse should infuse half of the total volume prescribed for 24 hr for a client who has sustained a burn injury over the first 8 hr. Therefore, the nurse should complete the calculation using half of 5,200 mL, which is 2,600 mL.Step 1: What is the unit of measurement the nurse should calculate? mL/hr Step 2: What is the volume the nurse should infuse? 2,600 mL Step 3: What is the total infusion time? 8 hr Step 4: Should the nurse convert the units of measurement? No Step 5: Set up an equation and solve for X. Volume (mL)X mL/hr =
Time (hr)2,600 mLX mL/hr =
8 hrX mL/hr = 325 mL/hrStep 6: Round if necessary. Step 7: Reassess to determine if the amount to administer makes sense. If the amount prescribed is 2,600 mL to infuse over 8 hr, it makes sense to administer 325 mL/hr. Follow these steps to calculate the infusion rate using the Dimensional Analysis method of calculation:The nurse should infuse half of the total volume prescribed for 24 hr for a client who has sustained a burn injury over the first 8 hr. Therefore, the nurse should complete the calculation using half of 5,200 mL, which is 2,600 mL.Step 1: What is the unit of measurement the nurse should calculate? (Place the unit of measure being calculated on the left side of the equation.) X mL/hr = Step 2: Determine the ratio that contains the same unit as the unit being calculated. (Place the ratio on the right side of the equation, ensuring that the unit in the numerator matches the unit being calculated.) 2,600 mLX mL/hr =
8 hrStep 3: Place any remaining ratios that are relevant to the item on the right side of the equation, along with any needed conversion factors, to cancel out unwanted units of measurement. 2,600 mLX mL/hr =
8 hrStep 4: Solve for X. X mL/hr = 325 mL/hrStep 5: Round if necessary. Step 6: Reassess to determine if the amount to administer makes sense. If the amount prescribed is 2,600 mL to infuse over 8 hr, it makes sense to administer 325 mL/hr. InCorrect Rationale: Follow these steps to calculate the infusion rate using the Ratio and Proportion or Desired Over Have method of calculation:The nurse should infuse half of the total volume prescribed for 24 hr for a client who has sustained a burn injury over the first 8 hr. Therefore, the nurse should complete the calculation using half of 5,200 mL, which is 2,600 mL.Step 1: What is the unit of measurement the nurse should calculate? mL/hr Step 2: What is the volume the nurse should infuse? 2,600 mL Step 3: What is the total infusion time? 8 hr Step 4: Should the nurse convert the units of measurement? No Step 5: Set up an equation and solve for X. Volume (mL)X mL/hr =
Time (hr)2,600 mLX mL/hr =
8 hrX mL/hr = 325 mL/hrStep 6: Round if necessary. Step 7: Reassess to determine if the amount to administer makes sense. If the amount prescribed is 2,600 mL to infuse over 8 hr, it makes sense to administer 325 mL/hr. Follow these steps to calculate the infusion rate using the Dimensional Analysis method of calculation:The nurse should infuse half of the total volume prescribed for 24 hr for a client who has sustained a burn injury over the first 8 hr. Therefore, the nurse should complete the calculation using half of 5,200 mL, which is 2,600 mL.Step 1: What is the unit of measurement the nurse should calculate? (Place the unit of measure being calculated on the left side of the equation.) X mL/hr = Step 2: Determine the ratio that contains the same unit as the unit being calculated. (Place the ratio on the right side of the equation, ensuring that the unit in the numerator matches the unit being calculated.) 2,600 mLX mL/hr =
8 hrStep 3: Place any remaining ratios that are relevant to the item on the right side of the equation, along with any needed conversion factors, to cancel out unwanted units of measurement. 2,600 mLX mL/hr =
8 hrStep 4: Created on:09/05/2024 Page 20 Detailed Answer Key AM RN CAPSTONE EXAM SUMMER 24 o and Proportion or Desired Over Have method of calculation:The nurse should infuse half of the total volume prescribed for 24 hr for a client who has sustained a burn injury over the first 8 hr. Therefore, the nurse should complete the calculation using half of 5,200 mL, which is 2,600 mL.Step 1: What is the unit of measurement the nurse should calculate? mL/hr Step 2: What is the volume the nurse should infuse? 2,600 mL Step 3: What is the total infusion time? 8 hr Step 4: Should the nurse convert the units of measurement? No Step 5: Set up an equation and solve for X. Volume (mL)X mL/hr =
Time (hr)2,600 mLX mL/hr =
8 hrX mL/hr = 325 mL/hrStep 6: Round if necessary. Step 7: Reassess to determine if the amount to administer makes sense. If the amount prescribed is 2,600 mL to infuse over 8 hr, it makes sense to administer 325 mL/hr. Follow these steps to calculate the infusion rate using the Dimensional Analysis method of calculation:The nurse should infuse half of the total volume prescribed for 24 hr for a client who has sustained a burn injury over the first 8 hr. Therefore, the nurse should complete the calculation using half of 5,200 mL, which is 2,600 mL.Step 1: What is the unit of measurement the nurse should calculate? (Place the unit of measure being calculated on the left side of the equation.) X mL/hr = Step 2: Determine the ratio that contains the same unit as the unit being calculated. (Place the ratio on the right side of the equation, ensuring that the unit in the numerator matches the unit being calculated.) 2,600 mLX mL/hr =
8 hrStep 3: Place any remaining ratios that are relevant to the item on the right side of the equation, along with any needed conversion factors, to cancel out unwanted units of measurement. 2,600 mLX mL/hr =
8 hrStep 4: Solve for X. X mL/hr = 325 mL/hrStep 5: Round if necessary. Step 6: Reassess to determine if the amount to administer makes sense. If the amount prescribed is 2,600 mL to infuse over 8 hr, it makes sense to administer 325 mL/hr. 45. A nurse is preparing to administer 250 mg of an antibiotic IM. Available is 3 g/5 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) 0.4 mL Correct Rationale: Follow these steps for the Ratio and Proportion method of calculation:Step 1: What is the unit of measurement the nurse should calculate? mL Step 2: What is the dose the nurse should administer? Dose to administer = Desired 250 mg Step 3: What is the dose available? Dose available = Have 3 g Step 4: Should the nurse convert the units of measurement? Yes (g does not equal mg) 1 g 3 g
=
1,000 mgX mgX mg = 3,000 mgStep 5: What is the quantity of the dose available? 5 mL Step 6: Set up an equation and solve for X. HaveDesired
=
QuantityX3,000 mg250 mg
=
5 mLX mLX mL = 0.4166 mLStep 7: Round if necessary. 0.4166 = 0.4 mLStep 8: Determine whether the amount to administer makes sense. If there is 3 g (3,000 mg) in 5 mL and the prescription reads 250 mg, it makes sense to administer 0.4 mL. The nurse should administer 0.4 mL IM.Follow these steps for the Desired Over Have method of calculation:Step 1: What is the unit of measurement the nurse should calculate? mL Step 2: What is the dose the nurse should administer? Dose to administer = Desired 250 mg Step 3: What is the dose available? Dose available = Have 3 g Step 4: Should the nurse convert the units of measurement? Yes (g does not equal mg) 3
1
=
1,000 mgX mgX mg = 3,000 mgStep 5: What is the quantity of the dose available? 5 mL Step 6: Set up an equation and solve for X. HaveDesired
=
QuantityX3,000 mg250 mg
=
5 mLX mLX mL = 0.4166 mLStep 7: Round if necessary. 0.4166 = 0.4 mLStep 8: Determine whether the amount to administer makes sense. If there is 3 g (3,000 mg) in 5 mL and the prescription reads 250 mg, it makes sense to administer 0.4 mL. The nurse should administer 0.4 mL IM.Follow these steps for the Desired Over Have method of calculation:Step 1: What is the unit of measurement the nurse should calculate? mL Step 2: What is the dose the nurse should administer? Dose to administer = Desired 250 mg Step 3: What is the dose available? Dose available = Have 3 g Step 4: Should the nurse convert the units of measurement? Yes (g does not equal mg) 3
1
Have250
3,000
3 gStep 3: Place any remaining ratios that are relevant to the item on the right side of the equation, along with any needed conversion factors, to cancel out unwanted units of measurement. 5 mL1
×
×
3
=
1,000 mgX mgX mg = 3,000 mgStep 5: What is the quantity of the dose available? 5 mL Step 6: Set up an equation and solve for X. HaveDesired
=
QuantityX3,000 mg250 mg
=
5 mLX mLX mL = 0.4166 mLStep 7: Round if necessary. 0.4166 = 0.4 mLStep 8: Determine whether the amount to administer makes sense. If there is 3 g (3,000 mg) in 5 mL and the prescription reads 250 mg, it makes sense to administer 0.4 mL. The nurse should administer 0.4 mL IM.Follow these steps for the Desired Over Have method of calculation:Step 1: What is the unit of measurement the nurse should calculate? mL Step 2: What is the dose the nurse should administer? Dose to administer = Desired 250 mg Step 3: What is the dose available? Dose available = Have 3 g Step 4: Should the nurse convert the units of measurement? Yes (g does not equal mg) 3
1
=
1,000 mgX mgX mg = 3,000 mgStep 5: What is the quantity of the dose available? 5 mL Step 6: Set up an equation and solve for X. HaveDesired
=
QuantityX3,000 mg250 mg
=
5 mLX mLX mL = 0.4166 mLStep 7: Round if necessary. 0.4166 = 0.4 mLStep 8: Determine whether the amount to administer makes sense. If there is 3 g (3,000 mg) in 5 mL and the prescription reads 250 mg, it makes sense to administer 0.4 mL. The nurse should administer 0.4 mL IM.Follow these steps for the Desired Over Have method of calculation:Step 1: What is the unit of measurement the nurse should calculate? mL Step 2: What is the dose the nurse should administer? Dose to administer = Desired 250 mg Step 3: What is the dose available? Dose available = Have 3 g Step 4: Should the nurse convert the units of measurement? Yes (g does not equal mg) 3
1
Have250
3,000
3 gStep 3: Place any remaining ratios that are relevant to the item on the right side of the equation, along with any needed conversion factors, to cancel out unwanted units of measurement. 5 mL1
×
×
3
=
QuantityX5,000 units2,000 units
=
1 mLX mLX mL = 0.4 mLStep 7: Round if necessary. Created on:09/05/2024 Page 23 Detailed Answer Key AM RN CAPSTONE EXAM SUMMER 24 t;/b>Step 1: What is the unit of measurement the nurse should calculate? mL Step 2: What is the dose the nurse should administer? Dose to administer = Desired 2,000 units Step 3: What is the dose available? Dose available = Have 5,000 units Step 4: Should the nurse convert the units of measurement? No Step 5: What is the quantity of the dose available? 1 mL Step 6: Set up an equation and solve for X. HaveDesired
=
QuantityX5,000 units2,000 units
=
1 mLX mLX mL = 0.4 mLStep 7: Round if necessary. Step 8: Reassess to determine whether the amount to administer makes sense. If there are 5,000 units/mL and the provider prescribed 2,000 units, it makes sense to administer 0.4 mL. The nurse should administer heparin 0.4 mL by IV bolus.Follow these steps for the Desired Over Have method of calculation:Step 1: What is the unit of measurement the nurse should calculate? mL Step 2: What is the dose the nurse should administer? Dose to administer = Desired 2,000 units Step 3: What is the dose available? Dose available = Have 5,000 units Step 4: Should the nurse convert the units of measurement? No Step 5: What is the quantity of the dose available? 1 mL Step 6: Set up an equation and solve for X. Desired × QuantityX =
Have2,000
5,000
5,000 unitsStep 3: Place any remaining ratios that are relevant to the item on the right side of the equation, along with any needed conversion factors, to cancel out unwanted units of measurement. 1 mL2,000
×
5,000
=
QuantityX5,000 units2,000 units
=
1 mLX mLX mL = 0.4 mLStep 7: Round if necessary. Step 8: Reassess to determine whether the amount to administer makes sense. If there are 5,000 units/mL and the provider prescribed 2,000 units, it makes sense to administer 0.4 mL. The nurse should administer heparin 0.4 mL by IV bolus.Follow these steps for the Desired Over Have method of calculation:Step 1: What is the unit of measurement the nurse should calculate? mL Step 2: What is the dose the nurse should administer? Dose to administer = Desired 2,000 units Step 3: What is the dose available? Dose available = Have 5,000 units Step 4: Should the nurse convert the units of measurement? No Step 5: What is the quantity of the dose available? 1 mL Step 6: Set up an equation and solve for X. Desired × QuantityX =
Have2,000
5,000
Have2,000
5,000
5,000 unitsStep 3: Place any remaining ratios that are relevant to the item on the right side of the equation, along with any needed conversion factors, to cancel out unwanted units of measurement. 1 mL2,000
×
5,000
=
QuantityX1 mg5 mg
=
1 mLX mLX mL = 5 mLStep 7: Round if necessary. Step 8: Reassess to determine whether the amount to administer makes sense. If there is 1 mg/mL and the prescription reads 5 mg, it makes sense to administer 5 mL. The nurse should administer metoprolol 5 mL IV per dose.Follow these steps for the Desired Over Have method of calculation:Step 1: What is the unit of measurement the nurse should calculate? mL Step 2: What is the dose the nurse should administer? Dose to administer = Desired 5 mg Step 3: What is the dose available? Dose available = Have 1 mg Step 4: Should the nurse convert the units of measurement? No Step 5: What is the quantity of the dose available? 1 mL Step 6: Set up an equation and solve for X. Desired × QuantityX =
Have5
1
1 mgStep 3: Place any remaining ratios that are relevant to the item on the right side of the equation, along with any needed conversion factors, to cancel out unwanted units of measurement. 1 mL5
×
1
=
QuantityX1 mg5 mg
=
1 mLX mLX mL = 5 mLStep 7: Round if necessary. Step 8: Reassess to determine whether the amount to administer makes sense. If there is 1 mg/mL and the prescription reads 5 mg, it makes sense to administer 5 mL. The nurse should administer metoprolol 5 mL IV per dose.Follow these steps for the Desired Over Have method of calculation:Step 1: What is the unit of measurement the nurse should calculate? mL Step 2: What is the dose the nurse should administer? Dose to administer = Desired 5 mg Step 3: What is the dose available? Dose available = Have 1 mg Step 4: Should the nurse convert the units of measurement? No Step 5: What is the quantity of the dose available? 1 mL Step 6: Set up an equation and solve for X. Desired × QuantityX =
Have5
1
1 mgStep 3: Place any remaining ratios that are relevant to the item on the right side of the equation, along with any needed conversion factors, to cancel out unwanted units of measurement. 1 mL5
×
1
Abundant lanugo is incorrect. Abundant lanugo is seen in preterm (gestational age of less than 37 weeks) newborns.
Vernix in folds and creases is incorrect Vernix in the folds and creases is seen in mature, term newborns. Created on:09/05/2024 Page 34 Detailed Answer Key AM RN CAPSTONE EXAM SUMMER 24 66. A nurse is admitting a client who has a diagnosis of preterm labor. The nurse anticipates a prescription by the provider for which of the following medications? (Select all that apply.) Answers cannot be displayed for this alternate item format. Rationale: Prostaglandin E2 is incorrect. Prostaglandin E2 is used to stimulate cervical ripening and hasten the onset of labor.
Indomethacin is correct. Indomethacin is used to relax uterine smooth muscles and suppress uterine activity in clients who have a diagnosis of preterm labor.
Magnesium sulfate is correct. Magnesium sulfate is a tocolytic and stops contractions in clients experiencing preterm labor.
Methylergonovine is incorrect. Methylergonovine promotes uterine contractions to manage postpartum hemorrhage.Oxytocin is incorrect. Oxytocin is used to induce and augment labor. 67. A nurse is admitting a client who is at 37 weeks of gestation and has severe gestational hypertension. Which of the following actions should the nurse expect to implement? (Select all that apply.) Answers cannot be displayed for this alternate item format. Rationale: Administer magnesium sulfate IV is correct. Magnesium sulfate IV is given as a tocolytic medication for preterm labor to relax smooth muscle of the uterus and as a treatment for preeclampsia. The underlying pathophysiology of preeclampsia is vasospasm. The nurse should closely monitor the client for signs of magnesium toxicity, such as loss of patellar reflexes, respiratory depression, cardiac arrhythmias, cardiac arrest, urinary retention, and serum magnesium levels higher than 8 mEq/L.Provide a dark, quiet environment is correct. A dark, quiet environment helps to decrease CNS stimulation, which minimizes the risk of seizures. Assess respiratory status every 4 hr is incorrect. The nurse should monitor the client's respiratory status closely because the client is at risk for respiratory depression. During an infusion of magnesium sulfate, the nurse should monitor the respiratory rate every 5 min and every 15 min during maintenance infusion. Depending on the client's response to the medication, the provider will prescribe for the vital signs to be monitored every 30 to 60 min thereafter.Evaluate neurologic status every 8 hr is incorrect. The nurse should evaluate the client's level of consciousness every hour.Ensure that calcium gluconate is readily available is correct. Calcium gluconate is the antidote for magnesium sulfate and should be readily available when administering magnesium sulfate. The nurse should be prepared to administer the medication in response to manifestations of magnesium toxicity, such as depressed respirations, oliguria, sudden drop in BP, loss of deep-tendon reflexes, and fetal distress. 68. A nurse is caring for a client who is at 36 weeks of gestation and who has a suspected placenta previa. Which of the following findings support this diagnosis? A. Painless red vaginal bleeding Rationale: Placenta previa is a condition of pregnancy when the placenta implants in the lower part of the uterus, partly or completely obstructing the cervical os (outlet to the vagina). Bright red, painless vaginal bleeding occurs in the second and third trimester. B. Increasing abdominal pain with a nonrelaxed uterus Rationale: Abruptio placenta is separation of the placenta from the site of uterine implantation before Created on:09/05/2024 Page 35 Detailed Answer Key AM RN CAPSTONE EXAM SUMMER 24 delivery of the fetus. When the placenta separates prematurely, there is internal bleeding, which is painful, and the uterus is nonrelaxed or becomes rigid as the separation advances. C. Abdominal pain with scant red vaginal bleeding Rationale: Placenta previa involves minimal to severe bright red vaginal bleeding in the absence of abdominal pain. D. Intermittent abdominal pain following passage of bloody mucus Rationale: Intermittent abdominal pain following passage of bloody mucus is a description of normal labor. The passage of bloody mucus represents the loss of the cervical mucous plug, also referred to as the "bloody show." 69. A nurse is caring for an antepartum client whose laboratory findings indicate a negative rubella titer. Which of the following is the correct interpretation of this data? A. The client is not experiencing a rubella infection at this time. Rationale: A negative rubella titer indicates the client is susceptible to the rubella virus. It does not indicate the presence or absence of a rubella infection. B. The client is immune to the rubella virus. Rationale: A negative rubella titer indicates the client is susceptible to the rubella virus. C. The client requires a rubella vaccination at this time. Rationale: Rubella vaccination during pregnancy is contraindicated because of possible injury to the developing fetus. D. The client requires a rubella immunization following delivery. Rationale: A negative rubella titer indicates that the client is susceptible to the rubella virus and needs vaccination following delivery. Immunization during pregnancy is contraindicated because of possible injury to the developing fetus. Following rubella immunization, the client should be cautioned not to conceive for 1 month. 70. A nurse has accepted a position on a pediatric unit and is learning about psychosocial development. Place Erikson's stages of psychosocial development in order from birth to adolescence. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) E. Trust vs. mistrust A. Autonomy vs. shame and doubt D. Initiative vs. guilt B. Industry vs. inferiority C. Identity vs. role confusion Created on:09/05/2024 Page 36 Detailed Answer Key AM RN CAPSTONE EXAM SUMMER 24 71. A nurse is preparing to administer acetaminophen 10 mg/kg/dose to a child who weighs 28 lb. The amount available is acetaminophen 120 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) 5.3 mL Correct Rationale: Follow these steps for the Ratio and Proportion method of calculation:Step 1: What is the unit of measurement the nurse should calculate? kg Step 2: Set up an equation and solve for X. 2.2 lbClient's weight in lb
=
1 kgX kg2.2 lb28 lb
=
1 kgX kgX kg = 12.7272 kgStep 3: What is the unit of measurement the nurse should calculate? mg Step 4: Set up an equation and solve for X. X mg = Dose per kg × Client's weight in kgX mg = 10 mg × 12.7272 X mg = 127.2727 mgStep 5: What is the unit of measurement the nurse should calculate? mL Step 6: What is the dose the nurse should administer? Dose to administer = Desired 127.2727 mg Step 7: What is the dose available? Dose available = Have 120 mg Step 8: Should the nurse convert the units of measurement? No Step 9: What is the quantity of the dose available? 5 mL Step 10: Set up an equation and solve for X. HaveDesired
=
QuantityX120 mg127.2727
=
5 mLX mLX mL = 5.3030 mLStep 11: Round if necessary. 5.3030 = 5.3 Step 12: Reassess to determine whether the amount to give makes sense. If there are 120 mg/5 mL and the amount prescribed is 127 mg, it makes sense to administer acetaminophen 5.3 mL.Follow these steps for the Desired Over Have method of calculation:Step 1: What is the unit of measurement the nurse should calculate? kg Step 2: Set up an equation and solve for X. Client's weight in lb × 1 kgX kg =
2.2 lb28
2.2
Have127.2727
120
120 mgStep 3: Place any remaining ratios that are relevant to the item on the right side of the equation, along with any needed conversion factors, to cancel out unwanted units of measurement. 5 mL10
×
×
×
120
=
1 kgX kg2.2 lb28 lb
=
1 kgX kgX kg = 12.7272 kgStep 3: What is the unit of measurement the nurse should calculate? mg Step 4: Set up an equation and solve for X. X mg = Dose per kg × Client's weight in kgX mg = 10 mg × 12.7272 X mg = 127.2727 mgStep 5: What is the unit of measurement the nurse should calculate? mL Step 6: What is the dose the nurse should administer? Dose to administer = Desired 127.2727 mg Step 7: What is the dose available? Dose available = Have 120 mg Step 8: Should the nurse convert the units of measurement? No Step 9: What is the quantity of the dose available? 5 mL Step 10: Set up an equation and solve for X. HaveDesired
=
QuantityX120 mg127.2727
=
5 mLX mLX mL = 5.3030 mLStep 11: Round if necessary. 5.3030 = 5.3 Step 12: Reassess to determine whether the amount to give makes sense. If there are 120 mg/5 mL and the amount prescribed is 127 mg, it makes sense to administer acetaminophen 5.3 mL.Follow these steps for the Desired Over Have method of calculation:Step 1: What is the unit of measurement the nurse should calculate? kg Step 2: Set up an equation and solve for X. Client's weight in lb × 1 kgX kg =
2.2 lb28
2.2
Have127.2727
120
120 mgStep 3: Place any remaining ratios that are relevant to the item on the right side of the equation, along with any needed conversion factors, to cancel out unwanted units of measurement. 5 mL10
×
×
×
120
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