RN Concept-Based Assessment Level 2 Online Practice B
Questions and Answers
A nurse is caring for a client who has pneumonia. -Resume tub baths in 24hr - - Monitor the
Which of the following actions is the priority for site daily for drainage
the nurse to take?
-Monitor intake and output The nurse should instruct the guardian to monitor
-Provide teaching about antibiotic therapy the site daily for manifestations of infection, such
-Administer the influenza vaccine as drainage, redness, and swelling. The guardian
-Observe the client perform incentive spirometry should report these findings to the provider.
- - Observe the client perform incentive
spirometry
A nurse is reviewing the medical record of a
When using the airway, breathing, and circulation client who is receiving total parenteral nutrition for
framework, the priority action the nurse should a malabsorption disorder. Which of the following
take is to observe the client perform incentive findings should the nurse identify as an indication
spirometry. Incentive spirometry improves gas that the client's nutritional status is improving?
exchange and oxygenation and stimulates -Intake of fluid is less than output of urine over
coughing, which assists in clearing secretions. the past 2 days
-1kg (2.2 lb) weight gain over the past 2 days
-Blood glucose 206 mg/dL
A nurse is assessing a client who has -Prealbumin 13 mg/dL - - 1 kg (2.2 lb)
hyperthyroidism and has been taking weight gain over the past 2 days
methimazole for 6 months. Which of the following
findings indicates a therapeutic response to the Total parenteral nutrition is administered to
medication clients who have inflammatory bowel disorders
-The client's skin is warm and moist and are unable to tolerate enteral nutrition. A
-The client reports sleeping longer during the weight gain of 0.5 kg (1.1 lb) daily is an indication
night that the client is responding to the parenteral
-The client is experiencing increased bowel nutrition.
movements
-The client's weight is 1.4 kg (3.1 lb) less than
baseline - - The client reports sleeping A nurse is performing a focused assessment on a
longer during the night client who has cholelithiasis and reports pain.
Which of the following areas should the nurse
The nurse should recognize that insomnia is a assess? - - Right upper quadrant
manifestation of hyperthyroidism. The client's
ability to sleep longer during the night indicates a The nurse should assess the gallbladder for the
therapeutic response to the medication. 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
A nurse is planning discharge teaching for the radiate from the right upper quadrant of the
guardian of a child who had a cardiac client's abdomen to the client's right shoulder.
catheterization. Which of the following
instructions should the nurse include?
-Monitor the site daily for drainage The nurse is providing discharge teaching to a
-Leave the pressure dressing on the 48 hr client about managing diverticulitis. Which of the
-Administer aspirin if the child reports pain following statements should the nurse include in
,RN Concept-Based Assessment Level 2 Online Practice B
Questions and Answers
the teaching? -Block one nostril when blowing your nose
-"Use bisacodyl suppositories to stimulate a -Use an ear wick candle to remove excess
bowel movement" cerumen from the canal
-"Avoid lifting objects greater than 50 pounds" -Lubricate cotton-tipped applicators with mineral
-"Consume a clear liquid diet until symptoms oil to clean the ear canal - - Keep your
resolve" mouth open when sneezing
-"Take a probiotic 15 minutes after taking a
prescribed antibiotic to prevent antibiotic-related The nurse should instruct the client to keep the
diarrhea" - - "Consume a clear liquid diet mouth open while sneezing to reduce the
until symptoms resolve" pressure in the middle ear. Sudden pressure
changes can damage the ossicles and perforate
The nurse should recommend the client the ear drum.
consume a clear liquid diet until manifestations
such as abdominal pain, nausea, and vomiting
have resolved. A clear liquid diet is low in fiber A nurse is teaching a client who recently lost his
and does not stimulate intestinal motility. partner to a terminal illness. The client asks how
his 4-year-old son is expected to react to the
death of his partner. Which of the following
A nurse is providing teaching to a client who has information should the nurse include in the
a methicillin-resistant Staphylococcus aureus teaching?
(MRSA) skin infection. Which of the following -A preschooler has no concept of death
client statements indicates an understanding of -A preschooler is often interested in what
the management of antibiotic resistant happens to the body after death
infections? -A preschooler often believes that death is
-I will keep the infected area open to air to help it reversible
heal -A preschooler understands that death happens
-I can sleep in the same bed as my partner after I to everyone - - A preschooler often
have been taking antibiotics for 24 hours believes that death is reversible
-I should sit on upholstered chairs instead of
hardback chairs The nurse should identify that preschoolers tend
-I will wash all uninfected skin areas with a fresh to have difficulty understanding the reality of
washcloth - - I will wash all uninfected skin death and often believe that it is reversible.
areas with a fresh washcloth Because of magical thinking, the preschooler
might think that his thoughts or behavior might
The nurse should instruct the client to wash the have caused the person to die.
uninfected skin areas with a fresh washcloth to
prevent contamination of the unaffected areas of
the skin with the MRSA infection. A nurse is assessing a client who has gestational
diabetes and ketoacidosis. Which of the following
manifestations should the nurse expect?
A nurse is providing teaching to a client about -Increased urination
preventing hearing loss from trauma. Which of -Sweating
the following instructions should the nurse -Dizziness
include in the teaching? -Loose stools - - Increased urination
-Keep your mouth open when sneezing
, RN Concept-Based Assessment Level 2 Online Practice B
Questions and Answers
The nurse should expect the client to exhibit with one-half cup of bleach
manifestations of hyperglycemia, including
increased thirst, nausea, vomiting, increased The client should soak for at least 5 min in a
urination, flushed dry skin, acetone breath odor, bathtub filled one-fourth full of water with ½ cup
and a weak, rapid pulse. of bleach once or twice per week. This will help
prevent reoccurrence of the infection.
A nurse is assessing a client who has an external
fixator to the right lower arm following A nurse is caring for a client who is experiencing
musculoskeletal trauma. Which of the following an asthma attack. Which of the following
findings should indicate to the nurse that the procedures should the nurse use to assess the
client has developed compartment syndrome? client's respiratory status?
-Serous drainage is present on the pin site -Peak expiratory flow meter testing
dressings -Spirometry monitoring
-Flushing of the skin on the right arm -Pulmonary function testing
-Bounding pulse palpated in the radial artery -Chest x-ray - - Peak expiratory flow meter
-Numbness to the fingers on the right arm - testing
- Numbness to the fingers on the right arm
The peak expiratory flow meter provides a means
The nurse should identify a decrease in of evaluating the maximum flow of air the client
sensation, such as numbness and tingling of the expels during forceful exhalation. It provides
fingers, as one of the first indications that the information on how well asthma is being
client might be developing compartment controlled as a part of daily monitoring and can
syndrome of the right lower arm. Compartment be used when a client is having an asthma
syndrome is the result of edema and ischemia, a attack. The flow meter testing helps to gauge the
complication following musculoskeletal injury. peak-expiratory zone the client is experiencing
Other manifestations include increased pain, and determines if the client should use
paralysis, pallor, and decreased or absent immediate-acting bronchial dilator inhalers or
pulses. seek emergency help.
A nurse is providing teaching about home care A nurse is caring for a client who has renal calculi
with an adolescent client who has a skin infection and is taking oxybutynin for pain. Which of the
caused by MRSA. Which of the following client following findings should the nurse identify as an
statements indicates an understanding of the adverse effect of this medication?
teaching? -Increased salivation
-I will soak in a bathtub filled one-fourth full of -Bradycardia
water with one-half cup of bleach -Tinnitus
-I will wash my clothes in cold water and -Distended bladder - - Distended bladder
detergent
-I will throw away my razor after using it three The nurse should identify oxybutynin as having
times anticholinergic effects that can result in urinary
-I will apply imiquimod cream to the lesions retention. The nurse should monitor the client's
before going to bed each night - - I will intake and output and assess for bladder
soak in a bathtub filled one-fourth full of water distention.
Questions and Answers
A nurse is caring for a client who has pneumonia. -Resume tub baths in 24hr - - Monitor the
Which of the following actions is the priority for site daily for drainage
the nurse to take?
-Monitor intake and output The nurse should instruct the guardian to monitor
-Provide teaching about antibiotic therapy the site daily for manifestations of infection, such
-Administer the influenza vaccine as drainage, redness, and swelling. The guardian
-Observe the client perform incentive spirometry should report these findings to the provider.
- - Observe the client perform incentive
spirometry
A nurse is reviewing the medical record of a
When using the airway, breathing, and circulation client who is receiving total parenteral nutrition for
framework, the priority action the nurse should a malabsorption disorder. Which of the following
take is to observe the client perform incentive findings should the nurse identify as an indication
spirometry. Incentive spirometry improves gas that the client's nutritional status is improving?
exchange and oxygenation and stimulates -Intake of fluid is less than output of urine over
coughing, which assists in clearing secretions. the past 2 days
-1kg (2.2 lb) weight gain over the past 2 days
-Blood glucose 206 mg/dL
A nurse is assessing a client who has -Prealbumin 13 mg/dL - - 1 kg (2.2 lb)
hyperthyroidism and has been taking weight gain over the past 2 days
methimazole for 6 months. Which of the following
findings indicates a therapeutic response to the Total parenteral nutrition is administered to
medication clients who have inflammatory bowel disorders
-The client's skin is warm and moist and are unable to tolerate enteral nutrition. A
-The client reports sleeping longer during the weight gain of 0.5 kg (1.1 lb) daily is an indication
night that the client is responding to the parenteral
-The client is experiencing increased bowel nutrition.
movements
-The client's weight is 1.4 kg (3.1 lb) less than
baseline - - The client reports sleeping A nurse is performing a focused assessment on a
longer during the night client who has cholelithiasis and reports pain.
Which of the following areas should the nurse
The nurse should recognize that insomnia is a assess? - - Right upper quadrant
manifestation of hyperthyroidism. The client's
ability to sleep longer during the night indicates a The nurse should assess the gallbladder for the
therapeutic response to the medication. 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
A nurse is planning discharge teaching for the radiate from the right upper quadrant of the
guardian of a child who had a cardiac client's abdomen to the client's right shoulder.
catheterization. Which of the following
instructions should the nurse include?
-Monitor the site daily for drainage The nurse is providing discharge teaching to a
-Leave the pressure dressing on the 48 hr client about managing diverticulitis. Which of the
-Administer aspirin if the child reports pain following statements should the nurse include in
,RN Concept-Based Assessment Level 2 Online Practice B
Questions and Answers
the teaching? -Block one nostril when blowing your nose
-"Use bisacodyl suppositories to stimulate a -Use an ear wick candle to remove excess
bowel movement" cerumen from the canal
-"Avoid lifting objects greater than 50 pounds" -Lubricate cotton-tipped applicators with mineral
-"Consume a clear liquid diet until symptoms oil to clean the ear canal - - Keep your
resolve" mouth open when sneezing
-"Take a probiotic 15 minutes after taking a
prescribed antibiotic to prevent antibiotic-related The nurse should instruct the client to keep the
diarrhea" - - "Consume a clear liquid diet mouth open while sneezing to reduce the
until symptoms resolve" pressure in the middle ear. Sudden pressure
changes can damage the ossicles and perforate
The nurse should recommend the client the ear drum.
consume a clear liquid diet until manifestations
such as abdominal pain, nausea, and vomiting
have resolved. A clear liquid diet is low in fiber A nurse is teaching a client who recently lost his
and does not stimulate intestinal motility. partner to a terminal illness. The client asks how
his 4-year-old son is expected to react to the
death of his partner. Which of the following
A nurse is providing teaching to a client who has information should the nurse include in the
a methicillin-resistant Staphylococcus aureus teaching?
(MRSA) skin infection. Which of the following -A preschooler has no concept of death
client statements indicates an understanding of -A preschooler is often interested in what
the management of antibiotic resistant happens to the body after death
infections? -A preschooler often believes that death is
-I will keep the infected area open to air to help it reversible
heal -A preschooler understands that death happens
-I can sleep in the same bed as my partner after I to everyone - - A preschooler often
have been taking antibiotics for 24 hours believes that death is reversible
-I should sit on upholstered chairs instead of
hardback chairs The nurse should identify that preschoolers tend
-I will wash all uninfected skin areas with a fresh to have difficulty understanding the reality of
washcloth - - I will wash all uninfected skin death and often believe that it is reversible.
areas with a fresh washcloth Because of magical thinking, the preschooler
might think that his thoughts or behavior might
The nurse should instruct the client to wash the have caused the person to die.
uninfected skin areas with a fresh washcloth to
prevent contamination of the unaffected areas of
the skin with the MRSA infection. A nurse is assessing a client who has gestational
diabetes and ketoacidosis. Which of the following
manifestations should the nurse expect?
A nurse is providing teaching to a client about -Increased urination
preventing hearing loss from trauma. Which of -Sweating
the following instructions should the nurse -Dizziness
include in the teaching? -Loose stools - - Increased urination
-Keep your mouth open when sneezing
, RN Concept-Based Assessment Level 2 Online Practice B
Questions and Answers
The nurse should expect the client to exhibit with one-half cup of bleach
manifestations of hyperglycemia, including
increased thirst, nausea, vomiting, increased The client should soak for at least 5 min in a
urination, flushed dry skin, acetone breath odor, bathtub filled one-fourth full of water with ½ cup
and a weak, rapid pulse. of bleach once or twice per week. This will help
prevent reoccurrence of the infection.
A nurse is assessing a client who has an external
fixator to the right lower arm following A nurse is caring for a client who is experiencing
musculoskeletal trauma. Which of the following an asthma attack. Which of the following
findings should indicate to the nurse that the procedures should the nurse use to assess the
client has developed compartment syndrome? client's respiratory status?
-Serous drainage is present on the pin site -Peak expiratory flow meter testing
dressings -Spirometry monitoring
-Flushing of the skin on the right arm -Pulmonary function testing
-Bounding pulse palpated in the radial artery -Chest x-ray - - Peak expiratory flow meter
-Numbness to the fingers on the right arm - testing
- Numbness to the fingers on the right arm
The peak expiratory flow meter provides a means
The nurse should identify a decrease in of evaluating the maximum flow of air the client
sensation, such as numbness and tingling of the expels during forceful exhalation. It provides
fingers, as one of the first indications that the information on how well asthma is being
client might be developing compartment controlled as a part of daily monitoring and can
syndrome of the right lower arm. Compartment be used when a client is having an asthma
syndrome is the result of edema and ischemia, a attack. The flow meter testing helps to gauge the
complication following musculoskeletal injury. peak-expiratory zone the client is experiencing
Other manifestations include increased pain, and determines if the client should use
paralysis, pallor, and decreased or absent immediate-acting bronchial dilator inhalers or
pulses. seek emergency help.
A nurse is providing teaching about home care A nurse is caring for a client who has renal calculi
with an adolescent client who has a skin infection and is taking oxybutynin for pain. Which of the
caused by MRSA. Which of the following client following findings should the nurse identify as an
statements indicates an understanding of the adverse effect of this medication?
teaching? -Increased salivation
-I will soak in a bathtub filled one-fourth full of -Bradycardia
water with one-half cup of bleach -Tinnitus
-I will wash my clothes in cold water and -Distended bladder - - Distended bladder
detergent
-I will throw away my razor after using it three The nurse should identify oxybutynin as having
times anticholinergic effects that can result in urinary
-I will apply imiquimod cream to the lesions retention. The nurse should monitor the client's
before going to bed each night - - I will intake and output and assess for bladder
soak in a bathtub filled one-fourth full of water distention.
