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RN CONCEPT-BASED ASSESSMENT
LEVEL 2 QUESTIONS AND ANSWERS
2025
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 - correct
answer- 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.
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 - correct
answer- The client reports sleeping longer during the night
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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 - correct answer- 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.
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
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-Prealbumin 13 mg/dL - correct answer- 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? - correct answer- 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.
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"
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-"Take a probiotic 15 minutes after taking a prescribed antibiotic
to prevent antibiotic-related diarrhea" - correct 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 -
correct answer- I 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.
RN CONCEPT-BASED ASSESSMENT
LEVEL 2 QUESTIONS AND ANSWERS
2025
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 - correct
answer- 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.
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 - correct
answer- The client reports sleeping longer during the night
,2 | Page
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 - correct answer- 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.
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
,3 | Page
-Prealbumin 13 mg/dL - correct answer- 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? - correct answer- 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.
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"
, 4 | Page
-"Take a probiotic 15 minutes after taking a prescribed antibiotic
to prevent antibiotic-related diarrhea" - correct 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 -
correct answer- I 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.
