RN Concept-Based Assessment Level 2
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A nurse is caring for a client who has pneumonia. Which of the
following actions is the priority for the nurse to take?
-Monitor intake and output
-Provide teaching about antibiotic therapy
-Administer the influenza vaccine
-Observe the client perform incentive spirometry
----Solution----Observe the client perform incentive spirometry
When using the airway, breathing, and circulation framework, the
priority action the nurse should take is to observe the client perform
incentive spirometry. Incentive spirometry improves gas exchange and
oxygenation and stimulates coughing, which assists in clearing
secretions.
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A nurse is assessing a client who has hyperthyroidism and has been
taking methimazole for 6 months. Which of the following findings
indicates a therapeutic response to the medication
-The client's skin is warm and moist
-The client reports sleeping longer during the night
-The client is experiencing increased bowel movements
-The client's weight is 1.4 kg (3.1 lb) less than baseline
----Solution----The client reports sleeping longer during the night
The nurse should recognize that insomnia is a manifestation of
hyperthyroidism. The client's ability to sleep longer during the night
indicates a therapeutic response to the medication.
A nurse is planning discharge teaching for the guardian of a child who
had a cardiac catheterization. Which of the following instructions should
the nurse include?
-Monitor the site daily for drainage
-Leave the pressure dressing on the 48 hr
-Administer aspirin if the child reports pain
-Resume tub baths in 24hr
----Solution----Monitor the site daily for drainage
The nurse should instruct the guardian to monitor the site daily for
manifestations of infection, such as drainage, redness, and swelling. The
guardian should report these findings to the provider.
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A nurse is reviewing the medical record of a client who is receiving total
parenteral nutrition for a malabsorption disorder. Which of the following
findings should the nurse identify as an indication that the client's
nutritional status is improving?
-Intake of fluid is less than output of urine over the past 2 days
-1kg (2.2 lb) weight gain over the past 2 days
-Blood glucose 206 mg/dL
-Prealbumin 13 mg/dL
----Solution----1 kg (2.2 lb) weight gain over the past 2 days
Total parenteral nutrition is administered to clients who have
inflammatory bowel disorders and are unable to tolerate enteral
nutrition. A weight gain of 0.5 kg (1.1 lb) daily is an indication that the
client is responding to the parenteral nutrition.
A nurse is performing a focused assessment on a client who has
cholelithiasis and reports pain. Which of the following areas should the
nurse assess?
----Solution----Right upper quadrant
The nurse should assess the gallbladder for the presence of pain or
discomfort as a result of biliary colic, which is caused by a gallbladder
stone obstructing the bile duct. The pain can radiate from the right upper
quadrant of the client's abdomen to the client's right shoulder.
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The nurse is providing discharge teaching to a client about managing
diverticulitis. Which of the following statements should the nurse
include in the teaching?
-"Use bisacodyl suppositories to stimulate a bowel movement"
-"Avoid lifting objects greater than 50 pounds"
-"Consume a clear liquid diet until symptoms resolve"
-"Take a probiotic 15 minutes after taking a prescribed antibiotic to
prevent antibiotic-related diarrhea"
----Solution----"Consume a clear liquid diet until symptoms resolve"
The nurse should recommend the client consume a clear liquid diet until
manifestations such as abdominal pain, nausea, and vomiting have
resolved. A clear liquid diet is low in fiber and does not stimulate
intestinal motility.
A nurse is providing teaching to a client who has a methicillin-resistant
Staphylococcus aureus (MRSA) skin infection. Which of the following
client statements indicates an understanding of the management of
antibiotic resistant infections?
-I will keep the infected area open to air to help it heal
-I can sleep in the same bed as my partner after I have been taking
antibiotics for 24 hours
-I should sit on upholstered chairs instead of hardback chairs
-I will wash all uninfected skin areas with a fresh washcloth
----Solution----I will wash all uninfected skin areas with a fresh
washcloth