ATI RN Concept-Based Assessment Level 2 Exam (Latest 2023/ 2024) Questions and Verified Answers with Rationales| 100% Correct| Grade A

ATI RN Concept-Based Assessment Level 2 Exam (Latest 2023/ 2024) Questions and Verified Answers with Rationales| 100% Correct| Grade A Q: A nurse is assessing a client who has appendicitis. Which of the following findings should the nurse report to the provider immediately? WBC 16,000/mm³ Board-like abdomen Nausea and vomiting Temperature of 38° C (100.4° F) Answer: Board-like abdomen When using the urgent vs. nonurgent approach to client care, the nurse should identify that a board-like abdomen is the priority finding indicating peritonitis. The nurse should notify the provider immediately. Q: A nurse is teaching a client who has gastroesophageal reflux disease about ways to prevent reflux. Which of the following information should the nurse include in the teaching? Drink tomato juice with the breakfast meal. Suck on peppermint when having indigestion. Elevate the head of the bed 10 cm (4 in) using wooden blocks. Plan to finish eating at least 3 hr before bedtime. Answer: Plan to finish eating at least 3 hr before bedtime. The nurse should encourage the client not to eat anything at least 3 hr before bedtime to prevent reflux. Q: A nurse is teaching a client who has a deep-vein thrombosis about a new prescription for warfarin. Which of the following client statements indicates an understanding of the teaching? "I will stop taking the medication immediately if I experience nausea." "I should contact my provider if I notice a pink-tinged color to my urine." "I will increase my dietary intake of spinach." "I will not be able to use an electric razor while I am taking this medication." Answer: "I should contact my provider if I notice a pink-tinged color to my urine." The nurse should instruct the client to monitor for blood in the urine. The client should report a pink-tinged urine color to the provider. Q: A nurse is reviewing the urinalysis results of a client who has completed a 14-day course of ciprofloxacin to treat pyelonephritis. Which of the following values should indicate to the nurse that the client has a continuing infection? Negative nitrites RBCs < 2 Positive leukocyte esterase Amber-colored urine Answer: Positive leukocyte esterase The nurse should identify that a positive leukocyte esterase test is an indication of the presence of WBCs in the urine and the presence of continued infection. Q: A nurse is assessing a client for manifestations of grief after having a colostomy for removal of colon cancer. Which of the following findings indicates to the nurse that the client has accepted the loss? Becomes angry when it is time to perform colostomy care Touches the colostomy stoma when the bag is changed Looks away as the nurse empties the colostomy bag Tells others that it will be nice to have a normal bowel movement again Answer: Touches the colostomy stoma when the bag is changed The client touching the colostomy stoma when the bag is changed should indicate to the nurse that the client is accepting and coping with the alteration of body image and has gone through the stages of grief. Q: A nurse is assessing a school-age child who has appendicitis with possible perforation. Which of the following findings should the nurse identify as a manifestation of peritonitis? Abdominal distention Bradycardia Hyperactive bowel sounds Slow, deep breathing Answer: Abdominal distention The nurse should identify that peritonitis is an inflammation of the lining of the abdominal wall. This inflammation, along with the ileus that develops, causes abdominal distention; therefore, the nurse should identify this as a manifestation of peritonitis. Q: A nurse is reviewing the medical record of a client who has a peptic ulcer. Which of the following findings is a priority to report to the provider? Melena stools Hemoglobin 7.6 mg/dL Weight gain of 1.4 kg (3 lb) in 2 weeks Dyspepsia during the day Answer: Hemoglobin 7.6 mg/dL When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding to report to the provider is the hemoglobin below the expected reference range, which in an indication of a peptic ulcer that is chronically bleeding. Q: A nurse in an emergency department is assessing a client who has hyperthermia. Which of the following findings should the nurse identify as an indication that the client has heat exhaustion? Hallucinations Vomiting Bradycardia Seizures Answer: Vomiting The nurse should identify that heat exhaustion is usually the result of excess sweating, leading to dehydration. Manifestations include nausea, vomiting, headache, dizziness, fainting, and a temperature typically between 38.3º C and 38.9º C (101º F and 102º F). Q: A nurse is providing teaching to a client who is experiencing malabsorption related to lactose intolerance. Which of the following foods should the nurse recommend to the client as the best nondairy source of calcium? Ground beef Collard greens Cauliflower Walnuts Answer: Collard greens The nurse should determine that collard greens are the best food source to recommend because 1 cup contains 268 mg of calcium per serving. Q: A nurse is planning care for a client who is postoperative and has developed left lower leg deep-vein thrombosis. Which of the following interventions should the nurse include in the plan of care? Initiate complete bed rest. Massage the left lower leg three times a day. Make sure the client's legs are elevated while in bed. Apply cold compresses to the left lower leg every 2 hr. Answer: Make sure the client's legs are elevated while in bed. The nurse should ensure the client elevates her legs in bed and wears antiembolic stockings to help prevent venous insufficiency. Q: A nurse is assessing a client who is 1 day postoperative following open ileostomy placement to treat an inflammatory bowel disorder. Which of the following findings is the priority for the nurse to report to the provider? The stool is a dark green liquid with a small amount of blood. The ileostomy output is 1,000 mL for the past 24 hr. The stoma is purple in color. The output from the NG tube has decreased over the past 24 hr. Answer: The stoma is purple in color. When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding to report to the provider is the color of the stoma. Stomas should be pink to bright red in color and shiny. A stoma that is pale bluish, dark red-purplish, or black in color is not receiving adequate blood supply.