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RN CONCEPT-BASED ASSESSMENT LEVEL 2
- A nurse is providing postoperative education for a client following a laparoscopic cholecystectomy for cholelithiasis. Which of the following client statements indicates an understanding of the teaching? a- "The adhesive bandages on my incision will fall off as the incision heals." b- "I will be able to take a shower in 1 week." c- "I will need to follow a liquid diet for the first 3 days after surgery." d- "I can begin to resume my normal activity level in 2 weeks. CORRECT: a - The nurse should instruct the client that the small adhesive bandages will lose their adhesiveness in 7 to 10 days. The client can then remove the bandages or allow the bandages to fall off over time as the incision heals. INCORRECT: b- The nurse should instruct the client that she can shower or bathe the day following the surgery. c- The nurse should instruct the client to resume a regular diet following surgery and slowly introduce foods containing fat to determine tolerance. d- The nurse should instruct the client to rest for the first 24 hours following surgery and then begin resuming normal activities. The client should be able to resume usual activities within 1 week.
- A nurse is assessing a client who has Graves' disease. Which of the following findings should the nurse expect? a- Somnolence b- Cold intolerance c- Exophthalmos d- Dry, scaly skin CORRECT: c - The nurse should expect a client who has Graves' disease, an autoimmune form of hyperthyroidism, to experience exophthalmos, which is protrusion of the eyeballs. INCORRECT: a- The nurse should expect a client who has hyperthyroidism to experience insomnia. Somnolence is a common manifestation of Hypothyroidism. b- The nurse should expect a client who has hyperthyroidism to experience heat intolerance. cold intolerance is a common manifestation of Hypothyroidism
d- The nurse should expect a client who has hyperthyroidism to exhibit warm, moist, and smooth skin. Cool, dry scaly skin is a common manifestation of Hypothyroidism.
- A nurse is teaching a client who has scabies about a new prescription for lindane lotion. Which of the following client statements indicates an understanding of the treatment for this parasitic infection? a- "I will apply the lotion once a day for 1 week." b_ "I will rub the lotion thoroughly from my face to my toes." c- "I will wash the lotion off 12 hours after I apply it." d- " I should avoid bathing for 6 hours prior to applying the lotion." CORRECT: c - The nurse should instruct the client to apply the lotion and leave it in place fore 8 to 12 hours and then remove it by washing it off. INCORRECT: a- The nurse should instruct the client to apply the lotion, once. If live mites are still present, the nurse should instruct the client to reapply a second application one week following the first application. b- The nurse should instruct the client to apply approximately 60mL of the lotion in a thin film covering the body from the neck down. d- The nurse should instruct the client to bathe with soap and water, dry the skin well, and allow it to cool prior to applying the lotion.
- A nurse is teaching a client who has GERD about ways to prevent reflux. Which of the following information should the nurse include in the teaching? a- Drink tomato juice with the breakfast meal. b- Suck on peppermint when having indigestion. c- Elevate the head of the bed 10 cm (4 in) using wooden blocks d- Plan to finish eating at least 3 hours before bedtime. CORRECT: d - The nurse should encourage the client not to eat anything at least 3 hours before bedtime to prevent reflux. INCORRECT: a- The nurse should tell the client not to drink tomato juice or any acidic beverages because acidic beverages can increase reflux. b- The nurse should encourage the client not to suck on peppermint because it increases reflux. c- The nurse should instruct the client to elevate the head of the bed 15.2 to 30.5 cm (6 to 12 in) by placing a foam wedge under the head of the bed to decrease reflux.
- A nurse is providing teaching to a client who has diabetes mellitus and a new prescription for extended-release metformin. Which of the following client statements indicates an understanding of the teaching? a- "I will avoid drinking grapefruit juice." b- "I will chew the medication if I can't swallow it whole." c- "I will call the doctor if I have muscle pain in my back." d- "I will take this medication on an empty stomach." CORRECT: c - Metformin, a biguanide, can cause lactic acidosis, which is a life-threatening complication manifesting as muscle aches, sleepiness, malaise, and hyperventilation. If these manifestations develop, the client should stop taking the medication and notify the provider immediately. INCORRECT: a- Grapefruit juice can alter the effects of many medications, including lovastatin, cyclosporine, and buspirone, but it does not affect extended-release metformin. b- Extended-release metformin is designed to be metabolized over a prolonged period of time. Chewing or crushing the tablets can result in excessive absorption of the medication all at once. d- The client should take extended-release metformin once a day with his evening meal to help improve absorption due to the slower gastrointestinal transit time overnight.
- A community health nurse is teaching a group of older adult clients about interventions to prevent pneumonia. Which of the following instructions should the nurse include in the teaching? a- "Obtain a pneumococcal vaccination every 2 years." b- "Contact your provider if you have a fever that lasts 18 hours." c- "Wash your hands when you return home from running errands." d- "Avoid exposure to cold air by shopping inside enclosed malls." CORRECT: c - The nurse should instruct clients that handwashing is one way to avoid organisms that can cause pneumonia. Handwashing after using the restroom or being in public areas can minimize the risk of developing pneumonia. INCORRECT: a- The nurse should recommend that clients who have chronic health conditions and those over the age of 65 obtain a pneumococcal vaccination. Some providers will administer a second vaccination after 5 years. b- The nurse should instruct clients who have a cold or influenza to notify their provider if they have a fever lasting more than 24 hours, if manifestations last longer than 7 days, or if manifestations worsen. Addressing viral or bacterial infections in the early stages can help prevent the development of pneumonia.
d- The nurse should instruct clients to avoid crowded public areas, such as a shopping mall, during cold and flu season, which occurs during the winter. Being in an enclosed space with a group of people increases the risk of transmission of respiratory bacteria.
- A nurse is assessing a client whose ABG results are pH 7.51, PaCO2 29 mmHg, and HCO3- 24 mEq/L. Which of the following findings should the nurse expect? a- Paresthesias b- Bradycardia c- Muscle flaccidity d- Respiratory depression CORRECT: a - One of the manifestations of respiratory alkalosis is numbness and tingling, or paresthesia, due to a decrease in calcium ionization. Other manifestations include lightheadedness, tachycardia, and cardiac dysrhythmias. INCORRECT: b- A client experiencing respiratory alkalosis will exhibit tachycardia. c- A client experiencing respiratory alkalosis will exhibit hyperreflexia and muscle cramping and twitching. d- A client experiencing respiratory alkalosis will exhibit an increase in the rate and depth of respirations.
- A nurse is providing discharge teaching for a client who had a lithotripsy to break up calculi in the right kidney. Which of the following should the nurse instruct the client to report to the provider? a- Bruising over the right flank area b- Blood-tinged urine c- Urine pH 6. d- Painful urination CORRECT: d - The nurse should instruct the client to immediately report flank or bladder pain, chills and fever, or difficulty urinating to the provider. Development of difficulty of urinating, including decreased urine output of pain with urination, can mean that the client is developing an infection or can signal recoccurrence of a stone. INCORRECT: a- The nurse should instruct the client that bruising over the affected kidney following lithotripsy is expected and does not need to be reported to the provider. b- The nurse should instruct the client that blood-tinged urine is a common occurrence for several days following lithotripsy and does not need to be reported to the provider.
c- Hypermagnesemia d- Hypernatremia CORRECT: c - The nurse should identify that frequent ingestion of antacids and laxatives that contain magnesium can cause hypermagnesemia. Manifestations include hypotension, bradycardia, absent deep tendon reflexes, weak skeletal muscle contractions, ECG changes, lethargy, and drowsiness that can progress to coma. INCORRECT: a- The nurse should identify that hypophosphatemia can cause muscle weakness, as well as seizures, nystagmus, confusion, chest and bone pain, and paresthesias. b- The nurse should identify that hypochloremia can cause dysrhythmias, as well as irritability, agitation, hyperactive deep tendon reflexes, bradypnea, and seizures. d- The nurse should identify that hypernatremia can cause lethargy, as well as fever, thirst, restlessness, hyperreflexia, nausea, vomiting, tachycardia, and hypertension.
- A nurse is providing teaching to the parent of an infant who has gastroesophageal reflux about home care. Which of the following statements by the parent indicates an understanding of the teaching? a- "I will feed my infant a larger amount of formula less frequently." b- "I should feed my infant a bottle of formula within 1 hr of bedtime." c- "I should place my infant on his side to sleep." d- " I should add 1 teaspoon of rice cereal to my infant's formula." CORRECT: d - The parent should add 1 teaspoon of rice cereal in order to thicken the formula. this will decrease the incidence of gastric reflux. INCORRECT: a- The parent should feed the infant smaller amounts of formula more frequently throughout the day. Smaller feedings decrease the likelihood of reflux occurring. b- The parent should avoid feeding the infant a bottle close to bedtime. Feeding prior to sleep increases the incidence of reflux of gastric contents. c- The parent should place the infant on his back to sleep. The parent can lay the infant in the prone position for a few minutes a day while continuously observing the infant for safety.
- A nurse in an emergency department is assessing a preschooler who has severe dehydration as a result of gastroenteritis and is receiving isotonic IV fluids. Which of the following findings should the nurse identify as an indication that the treatment is effective? a- Urine output 0.5 mL/kg/hr b- Capillary refill 3 seconds
c- Heart rate 148/min d- Brisk skin turgor CORRECT: d - The nurse should expect the child to have brisk skin turgor if fluid replacement therapy is effective. INCORRECT: a- The nurse should expect the child to have a urine output greater than 1 mL/kg/hr if fluid replacement therapy has been effective. b- The nurse should expect the child to have a capillary refill of 2 secs or less if fluid replacement therapy has been effective. c- Tachycardia is a manifestation of dehydration. The nurse should expect the child to have a heart rate within the expected reference range for a 3- to 4-year-old child if fluid replacement therapy is effective.
- A nurse is reviewing the laboratory report of a client who is taking exenatide to treat type 2 diabetes mellitus. The nurse should recognize that which of the following laboratory results is an indication of an adverse reaction to the medication? a- HbA1c 6.8% b- Hct 45% c- Creatinine 0.9% mg/dL d- Lipase 185 units/L CORRECT: d - The nurse should recognize that an elevated lipase is an indication of pancreatitis, which can indicate the client is experiencing an adverse effect to exenatide. Physical manifestations of pancreatitis include ongoing, severe abdominal pain and vomiting. INCORRECT: a- The nurse should recognize that a hemoglobin A1c value of 6.8% is an indication that the client's diabetes is well controlled, which is a therapeutic response to the exenatide. b- The nurse should recognize that a hematocrit of 45% is within the expected reference range of 42% to 52% for men and 37% to 47% for women. c- The nurse should recognize that a creatinine of 0.9 mg/dL is within the expected reference range. The nurse should monitor the client's BUN and creatinine levels because renal failure is an adverse effect of exenatide.
- A nurse is teaching a client who has atherosclerosis about self-care. Which of the following instructions should the nurse include in the teaching? a- Consume five to seven servings of red meat per week b- Limit daily calorie intake from saturated fat to 18%
c- 5% weight loss d- Absence of tears CORRECT: d- The nurse should expect an infant who has severe dehydration to have an absence of tears when crying. Other manifestations include tachycardia, hypotension, intense thirst, and oliguria or anuria. INCORRECT: a- The nurse should expect an infant who has mild dehydration to have a flat anterior fontanel. Manifestations of severe dehydration include, sunken anterior fontanel, parched mucus membranes, sunken eyeballs, and tachycardia. b- The nurse should expect to an infant who has moderate dehydration to have a capillary refill of 2 to 4 seconds. Manifestations of severe dehydration include capillary refill time of greater than 4 seconds, parched mucus membranes, sunken eyeballs, and tachycardia. c- The nurse should expect an infant who has mild dehydration to have a weight loss of 3 to 5%. Manifestations of severe dehydration include weight loss of greater than 10% , parched mucus membranes, sunken eyeballs, and tachycardia.
- A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? (Select all that apply." a- Nocturia b- Dependent edema c- Dyspnea d- Hacking cough e- Anorexia Correct: a, c, d - Left-sided heart failure causes oliguria during the day and nocturia during sleeping hours, pulmonary manifestations, such as dyspnea, orthopnea, crackles, and wheezes, and a hacking cough that worsens at night and eventually produces frothy sputum. INCORRECT: b- Dependent edema is a manifestatio of right-sided heart failure. e- Anorexia, nausea, and abdominal distention and pain are manifestations of right-sided heart failure.
- A nurse is assessing a client who has social phobia and reports feelings of fear and panic when at social gatherings. Which of the following medications should the nurse expect the provider to prescribe? a- Carbamazepine b- Risperidone
c- Paroxetine d- Quetiapine CORRECT: c - Paroxetine is a selective serotonin reuptake inhibitor that is used to treat social anxiety disorder. INCORRECT: a- Carbamazepine is a mood stabilizer and anticonvulsant medication that treats bipolar disorder, seizure disorders, generalized anxiety disorder, and alcohol use disorder. b- Risperidone is an antipsychotic medication that treats schizophrenia, bipolar disorder, and obsessive-complusive disorder d- Quetiapine is an antipsychotic medication that treats schizophrenia, bipolar disorder, and generalized anxiety disorder.
- A nurse is caring for a client who has cellulitis of the lower extremity. Which of the following actions should the nurse take? (Select all that apply.) a- Apply cold packs to the affected area b- Treat the affected area with propranolol c- Elevate the affected area 15.24 cm (6in) above the heart d- Place a dry heating pad over the affected area e- Administer cefazolin intermittent IV bolus. CORRECT: c, e INCORRECT: a- The nurse should apply warm, moist heat packs, not cold packs, to the affected area. Cold packs cause vasoconstriction and decrease blood flow to the affected area. b- The nurse should apply topical antibacterial agents or administer oral or IV antibiotics to treat cellulitis. Propranolol is an antihypertensive antiarrhythmic medication and is not used to treat cellulitis. d- The nurse should apply warm, moist heat packs, not to a heating pad, to the affected area every 2 to 4 hours to decrease inflammation by increasing blood flow through vasodilation and to promote healing.
- A nurse in an emergency department is assessing a client who reports severe constipation. The nurse should identify which of the following findings as an indication to that the client might have a small-bowel obstruction? a- Peripheral edema b- Minimal vomiting
CORRECT: d- The greatest risk is that the client can transmit tuberculosis to other individuals; therefore, the first action the nurse should take is to initiate airborne precautions for this client. The nurse should place the client in a private rook with negative air pressure and at least six air exchanges per hour and use an N95 mask while caring for the client. INCORRECT: a- The nurse should obtain a sputum sample for mycobacterial culture to confirm the diagnosis; however, there is another action the nurse should take first. b- The nurse should administer the prescribed antimycobacterial medications after obtaining the sputum specimen; however, there is another action the nurse should take first. c- The nurse should refer the client to a dietitian to plan for a diet that promotes weight gain; however, there is another action the nurse should take first.
- A nurse is providing discharge teaching to a client who is postoperative following a transurethral resection of the prostate (TURP) for treatment of benign prostatic hyperplasia. Which of the following instructions should the nurse include in the teaching? a- "Notify your provider if you notice small pieces of tissue in your urine." b- "Any urinary incontinence will be permanent." c- "Expect to see an increase in the amount of semen produced." d- "Perform Kegel exercises several times throughout the day." CORRECT: d - The nurse should instruct the client on the performance of Kegel exercises, or tightening and then relaxing the urinary sphincter, to assist the client in regaining urinary control and eliminate dribbling or the leakage of urine. The nurse should encourage the client to perform these exercises several times each day. INCORRECT: a- The nurse should instruct the client that his urine might contain small blood clots and pieces of tissue for several days following catheter removal. The nurse should encourage the client to increase fluid intake to 2 to 2.5 L daily to promote urination. b- The nurse should instruct the client that dribbling small amounts of urine is an expected finding following the removal of a catheter after undergoing a TURP. The nurse should advise the client that temporary measures to keep clothing dry might be necessary, but the dribbling is temporary and will decrease when sphincter control returns. c- The nurse should instruct the client that he might experience retrograde ejaculation following a TURP procedure, in which most of the semen flows into the bladder rather than being ejaculated.
- A nurse is providing teaching to a client who has chronic obstructive pulmonary disease (COPD). Which of the following statements should indicate to the nurse that the client understands the
teaching? a- "I should drink 1.5 liters of water daily to keep hydrated." b- "I should make my abdomen rise with each inhalation." c- "I should inhale through my mouth and exhale through my nose." d- "I should limit walks to 10 minutes daily in order to conserve my energy." CORRECT: b - Diaphragmatic, or abdominal, breathing consists of consciously breathing by moving the abdomen outward with each breath. Diaphragmatic breathing decreases shortness of breath by moving the diaphragm upward to promote removal of trapped air during exhalation. INCORRECT: a- The nurse should instruct the client to drink at least 2 to 3 L of water daily to remain hydrated and assist with thinning of oral secretions, which makes it easier to expel while coughing. c- The nurse should instruct the client to use pursed-lip breathing in which he inhales through his nose and exhales through pursed lips. This method prolongs the exhalation phase and removes air trapped in the airways. d- The nurse should instruct the client who has COPD to practice exercise training at least 20 min daily indoors or outdoors. This can be done by walking until dyspnea or other manifestations occur, resting 5 min, and then walking again until a total of 20 min is completed.
- A nurse is caring for a preschooler who has a terminal illness. Which of the following reactions to death should the nurse expect the preschooler to exhibit? (Select all that apply.) a- Fears transmitting their disease to others b- Personifies death as being a type of monster c- Exhibits interest in what happens to the body following death d- Believes death is a temporary type of sleep e- Believes that their own thoughts can cause death CORRECT: d, e INCORRECT: a- The nurse should expect a school-age child to have a fear of transmitting their disease to others. b- The nurse should expect a school-age child to personify death as evil or a type of monster. c- The nurse should expect a school-age child to be inquisitive about what happens to a body following death and to be interested in postmortem services.
- A school nurse is assessing a school-age child who has erythema infectiosum (fifth disease). Which of the following manifestations should the nurse expect?
