RN Concept-Based Assessment Level 2 Online
Practice B
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 - answerObserve 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.
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 - answerThe 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 - answerMonitor 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.
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 - answer1 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? - answerRight 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.
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" - answer"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 - answerI will wash all uninfected skin
areas with a fresh washcloth
The nurse should instruct the client to wash the uninfected skin areas with a fresh washcloth to
prevent contamination of the unaffected areas of the skin with the MRSA infection.
A nurse is providing teaching to a client about preventing hearing loss from trauma. Which of the
following instructions should the nurse include in the teaching?
-Keep your mouth open when sneezing
-Block one nostril when blowing your nose
-Use an ear wick candle to remove excess cerumen from the canal
-Lubricate cotton-tipped applicators with mineral oil to clean the ear canal - answerKeep your
mouth open when sneezing
The nurse should instruct the client to keep the mouth open while sneezing to reduce the
pressure in the middle ear. Sudden pressure changes can damage the ossicles and perforate the ear
Practice B
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 - answerObserve 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.
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 - answerThe 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 - answerMonitor 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.
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 - answer1 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? - answerRight 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.
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" - answer"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 - answerI will wash all uninfected skin
areas with a fresh washcloth
The nurse should instruct the client to wash the uninfected skin areas with a fresh washcloth to
prevent contamination of the unaffected areas of the skin with the MRSA infection.
A nurse is providing teaching to a client about preventing hearing loss from trauma. Which of the
following instructions should the nurse include in the teaching?
-Keep your mouth open when sneezing
-Block one nostril when blowing your nose
-Use an ear wick candle to remove excess cerumen from the canal
-Lubricate cotton-tipped applicators with mineral oil to clean the ear canal - answerKeep your
mouth open when sneezing
The nurse should instruct the client to keep the mouth open while sneezing to reduce the
pressure in the middle ear. Sudden pressure changes can damage the ossicles and perforate the ear
