RN Concept-Based Assessment Level 1 Practice B

RN Concept-Based Assessment Level 1 Practice B C A nurse is reviewing the medical record of a client prior to medication administration. Which of the following actions should the nurse plan to take? - ANS Instruct the client to refrain from taking St. John's wort. A nurse is preparing an in-service on different types of pain. Which of the following information should the nurse plan to include as a characteristic of acute pain? - ANS It is part of the bodies attempt to protect itself. A nurse is documenting information on a clients medical record. Which of the following injuries should the nurse make? - ANS Client reports no pain while ambulating in the hallway. A charge nurse is providing an educational session to a group of newly licensed nurses about the purpose of the national patient safety goals. Which of the following objectives should the nurse include as a component of the national patient safety goals? - ANS Decrease error related to invasive procedures. A nurse is caring for a client who has a history of depressive disorder. The client states, "it feels pointless to get up in the morning." Which of the following responses should the nurse make? - ANS It sounds as if life seems meaningless to you now. A nurse is administering a liquid oral medication from a multi does bottle to a client. The nurse calculate that the dose is to be administered as for ML. Which of the following actions should the nurse take? - ANS Labeled the medication after measuring the dosage. A nurse is teaching a group of Parents and guardians about identifying substance use disorder among adolescents. Which of the following adolescent behaviors should the nurse include as a possible indication of substance use disorder? - ANS Wearing dark glasses indoors A community health nurse is teaching a group of older adult client at a senior center. Which of the following factors should the nurse include as an age related change the increases the risk for constipation an older adult clients? - ANS Delayed gastric emptying. A nurse is disgusting informed consent with a group of newly licensed nurses. Which of the following actions is the responsibility of the nurse when obtaining informed consent? - ANS Verify that the client voluntarily gave consent for the procedure A nurse is providing handoff report on a client. Which of the following information should the nurse include in the report? - ANS The client is scheduled for a chest x-ray on the next shift. A nurse is teaching a newly licensed nurse about the patient self-determination act PDS a. Which of the following actions should the nurse include as an example of PSD a compliant? - ANS Informing clients they can decline any treatment the provider prescribes. A nurse is planning to teach a class about standard precautions and preventing punch her injuries. Which of the following information should the nurse include in the plan? - ANS Recap needles using the one hand it's good method. A nurse is assessing a client who has a rash on their hands and forearms after working in the garden. The nurse should identify that which of the following findings indicate contact dermatitis? - ANS Well defined margins in the erythematous area. A nurse is teaching a client who has chronic fatigue syndrome. Which of the following statements should the nurse include? - ANS Reduce stress by taking tai chi classes. A nurse is caring for a client who has a recent diagnosis of iron deficiency. The client asked the nurse for food suggestions to increase iron in their diet. Which of the following foods should the nurse recommend? - ANS Raisins. A nurse is initiating droplet precautions for a newly admitted client. Which of the following actions should the nurse take? (Select all. that apply). - ANS Place the patient in a private room. Ensure the client wears a face mask for transport to x-ray. A nurse is reviewing the advance directives of a client who is being sustained on life-support. The Family disagrees Regarding the continuation of life support measures. Which of the following individuals should the nurse identify as having the legal ability to determine the clients course of treatment? - ANS The clients younger child, who is the clients health care proxy. A nurse is caring for a client who has a pressure ulcer and a prescription for a culture to evaluate the effect of anabiotic therapy on one healing. Which of the following actions should the nurse take first when obtaining the culture? - ANS Remove dressings covering the wound. A nurse is assessing a 10 month old infant who has a urinary tract infection (UTI). Which of the following things should a nurse expect? - ANS Decreased appetite. A nurse is preparing to administer enoxaparin to a client via a subcutaneous injection. Which of the following actions should the nurse take? - ANS Administer the medication in the clients abdomen. A public health nurse is planning care to meet healthy people 2020 objectives. Which of the following interventions sure the nurse include to promote clients access to healthcare? - ANS Set up workshops to help people who are uninsured sign up for health coverage. A nurse is teaching the parents of a five month old infant who is breast-feeding about introduction of complementary foods. Which of the following statements should the nurse make? - ANS Give your baby iron fortified infant rice cereal's before starting other foods. A nurse is providing teaching about a mechanically altered, or level two, diet to the caregiver of a client who has dysphasia. Which of the following food selections should the nurse include? - ANS Mashed bananas. A nurse is providing teaching to the parent of a school age child who has juvenile idiopathic arthritis about pain management. Which of the following statements should the nurse include? - ANS Encourage the child to participate in physical play activities. A nurse is teaching a group of nurses about cultural competence related to clients who follow is Islamic dietary laws. Which of the following images of food should the nurse include in the teaching as appropriate for a client who the valley follows is Islamic dietary practices? - ANS Cheese pizza. A nurse is teaching a client who has acute ulcerative colitis and is prescribed a low fiber diet. Which of the following foods should the nurse instruct the client to eat? - ANS Flavored gelatin A nurse is caring for a client who uses a fentanyl transdermal patch to treat chronic pain and is experiencing breakthrough pain following a surgical procedure. Which of the following medications should the nurse expect to administer? - ANS oxycodone A nurse is teaching about applying the national safety patient goals to reduce healthcare associated infections in clients. Which of the following information should the nurse include in the teaching? - ANS Bathe clients using a chlorhexidine solution. A nurse is caring for a client who has a new diagnosis of diabetes Melitis us and states that they cannot afford the prescribed insulin. The nurse offers to refer the client to the facility social worker. Which of the following principles is the nurse demonstrating? - ANS Advocacy. A nurse is assessing a client who has an infection of the upper urinary tract. In which of the following locations sure the nurse expect the client to be experiencing pain? - ANS A (kidney location) A nurse on a mental health unit is planning an in-service for newly hired staff about the use of restraints. Which of the following information should the nurse include? - ANS Document a clients condition every 15 minutes while in restraints. A nurse is talking with the parents of a school aged child about managing enuresis. Which of the following parents statements indicates an understanding of the information? - ANS We will have him help change the bed linens after he has an accident. A nurse is irrigating a clients infected surgical wound to promote wound healing. Which of the following actions should the nurse take? - ANS Continue irrigating until clear solution drains from the wound. A nurse is preparing to administer acetaminophen drops 60 mg PO to an infant who has a fever. The amount available is 160 mg/5 mL. How many milliliters should the nurse administer? - ANS 1.9mL A nurse is teaching a class about documenting client care in paper charts. Which of the following instructions should the nurse include in the teaching? - ANS Correct charting errors as they occur a nurse is discussing the healthy people 2020 initiative with a group of newly licensed nurses. The nurse should identify that which of the following nursing interventions meet one of the healthy people 2020 objectives? - ANS Organizing an exercise program for a group of older adults in an independent living facility. In operating room nurse is teaching an in-service about standardize procedures to reduce the risk for client injury during surgery. Which of the following information should the nurse include? - ANS Mark the operative site prior to surgical procedures. A nurse is providing teaching about negative pressure wound therapy (NPWT) to a client who has a chronic pressure ulcer. Which of the following information should the nurse include? - ANS NPWT promote drainage of infectious materials from the wound. A nurse is discussing a wellness approach to preventing excessive nutrition intake with a group of clients. Which of the following statements should the nurse make? - ANS Keep a record of cues that trigger a desire to eat. A nurse is applying a bed safety monitoring device for a client. Which of the following actions should the nurse take? - ANS Connect the sensor pad to call the system. A nurse is teaching a client about carbon monoxide in home safety. The nurse should instruct the client that which of the following is a manifestation of carbon monoxide exposure? - ANS Blurred vision. A nurse is performing a fall risk assessment for a client. Which of the following findings should the nurse identify as a forest? - ANS The client has a history of urinary frequency. A nurse is monitoring a client who is three days post operative following amputation and reports a phantom limb pain (PLP). Which of the following actions should the nurse take first? - ANS ask the client to describe the pain sensations. A nurse is supervising a newly licensed nurse who is documenting care on for clients in the clients electronica medical records. The nurse should identify that which of the following notations indicates accurate documentation? - ANS The client is this oriented to place and date. A nurse is teaching a group of parents and guardians who have toddlers about home safety. Which of the following information should the nurse provide? - ANS Install deadbolts towards the top of the doors leading outside. A home health nurse is planning care for an older adult client who lives alone and reports having difficulty adhering to the medication regimen. The nurse should include which of the following interventions in the plan? - ANS Organize daily medications in a divided pillbox. A public health nurse is preparing to care for a community that has a large population of clients who practice the Islamic faith. Which of the following practices should the nurse anticipate when caring for clients in this community? - ANS Moving the floor to pray. A nurse is applying a belt restraint to a client. Which of the following actions should the nurse take? - ANS Tie the restraint to a moveable part of the client's bed frame. A nurse is assessing a client who has your role in the diocese and is experiencing acute pain. Which of the following manifestations should the nurse expect? - ANS Flank pain, fever, and hematuria A nurse in a long-term care facility is performing in admission assessment on a client who reports that they are currently observing lit. Which of the following questions should the nurse asked the client to identify ways to accommodate their religious practices in their plan of care? - ANS Would you like to abstain from meat on Fridays? A nurse is planning care for a client who is actively dying and has previously expressed a desire to adhere to Buddhist practices related to death. Which of the following actions should the nurse anticipate and confirm with the client to accommodate their preferences? - ANS Ensure that there is room for the family to stand at the head of the clients bed. A home health nurse is teaching a client about fire extinguishers. Which of the following instruction should the nurse include in the teaching? - ANS Call the fire department before using a fire extinguisher. A nurse in a mental health clinic is interviewing a client who has depressive disorder and identified as religious during intake. Which of the following client statement should the nurse identify as indicating spiritual distress? - ANS I am not even sure why I exist. A nurse discovers a medication omission from the previous ship and notifies the charge nurse. Which of the following statements should the charge nurse make? - ANS You should monitor the client for injury. A nurse is caring for a group of clients who have dark pigmented skin. For which of the following client should the nurse notify the provider? - ANS A child who has read pinpoint that on the palms of their hands. A nurse is planning care for a client who has urinary incontinence. Which of the following intervention should the nurse include in the plan? - ANS Clean the clients perineal area with a no rinse cleaner. A nurse is submitting dietary requests for a client who the valley follows Mormon dietary practices. The nurse should ask the client if they would like which of the following foods or beverages exclude it from Meals? - ANS Coffee A nurse is teaching a assistive personnel (AP) about manifestations of dysphasia. Which of the following manifestations to the nurse include? - ANS Storing food in the mouth after swallowing. A charge nurse is supervising a newly licensed nurse who is caring for a group of clients. For which of the following actions by the newly licensed nurse should the charge nurse intervene? - ANS Uses a square knot to attach a race restraint to a client. A nurse is caring for a client who has an indwelling urinary catheter. Which of the following manifestations should indicate to the nurse that the client is developing a catheter require infection? - ANS Low back pain. A nurse is planning care for a client who has dementia and continues to get out of bed without assistance. Which of the following actions should the nurse plan to take? Apply and electronics safety device to the bed. A nurse is caring for a client who reports nausea. Which of the following actions should the nurse take? - ANS Encourage The client to suck on a spoon full of ice chips several times an hour. A nurse is providing dietary teaching to a client who has diarrhea. Which of the following items should the nurse include in the teaching as an appropriate dietary choice? - ANS Tomato juice A nurse is preparing to calculate the medication dosage for an adult client who has a prescription for a weight-based medication. Which of the following actions should the nurse plan to take? - ANS Divide the clients weight in pounds by 2.2 to obtain their weight in kilograms. A nurse is teaching a group of assistive personnel about expected physical changes associated with aging. Which of the following information should a nurse include? - ANS decrease in sense of taste. A nurse is teaching a client about using nicotine chewing gum for smoking cessation. Which of the following instructions to the nurse include? - ANS Chew a piece of nicotine gum slowly and intermittently. The nurse is assessing a client who has received laboratory confirmation of a Clostridium difficile infection. Which of the findings should the nurse expect? - ANS Abdominal pain. A nurse is teaching a group of newly licensed nurse about providing emotional support to a client who has experienced a loss. Which of the following information should the nurse include in the teaching? - ANS Allow the client to express a negative response. A nurse is conducting a culture assessment on a client to understand the clients values and believes. Which of the following actions should the nurse take first? - ANS Reflect on their own cultural values. A nurse is teaching a class about cultural and religious differences in values and believes related to death. Which of the following information should the nurse include in the teaching regarding postmortem clients who the valley practice Orthodox Judaism? - ANS Clients body should not be left alone until after the funeral. A nurse is updating the plan of care for a patient who is experiencing chemotherapy induced nausea and vomiting. Which of the following interventions should a nurse include? - ANS Provide the client with room temperature foods. A nurse is performing a health screening assessment on a client. The nurse should identify that which of the following findings places the client at risk for type two diabetes Mellitus? - ANS History of a sedentary lifestyle. A nurse is part of an informatics committee to improve safety with medication administration. Which of the following recommendations to the nurse make to decrease the risk of errors at the bedside? - ANS Use an electronic medication administration record for documentation. A nurse is providing teaching to the guardians of a preschooler about preventing contact dermatitis. Which of the following guardian statements indicating understanding the teaching? - ANS Plants are among the most common causes of contact dermatitis. A nurse is performing a health screening assessment on a client. Which of the following findings should the nurse identify as a risk factor for developing colorectal cancer? - ANS History of polyps. A nurse is providing teaching about infant nutrition to the guardian of a one month old infant who is formula fed. Which of the following statements should the nurse include? - ANS Your baby should be consuming 18 to 21 ounces of formula per day. A nurse is caring for a client Who has Clostridium difficile. The nurse should identify that C.difficile can be transmitted through contact with which of the following? - ANS Stool. A nurse is assisting a client who is learning to use a walker following a stroke. The client states, "I wasn't sure I could do this, but I talked to my friend who uses crutches and they think I can." Which of the following responses should the nurse make? - ANS It sounds like your friends encouragement about using a walker was helpful. A nurse is teaching a group of newly licensed nurses about using abbreviations when transcribing prescriptions. Which of the following transcription should the nurse use as an example of the correct usage of abbreviations? - ANS Docusate sodium 100mg PO bid A nurse is teaching a client who has left-sided weakness in the history of falls to use a quad cane. In what order should the nurse provide the following instructions? - ANS Place the cane on the right side of your body, keep weight on both legs as you move they came forward, advance the cane 6 to 12 inches forward, move her left leg full until it is even with the cane. A nurse is providing Change of shift report on a client using the situation background assessment recommendation (SBAR) communication tool. The nurse should identify that which of the following information is included in the background step? - ANS Admission diagnosis An employee health nurse is providing an in-service on infection control procedures. Which of the following infection should a nurse identify as requiring contact isolation precautions? - ANS Vancomycin-resistant enterococci (VRE), Methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile A nurse is teaching an in-service about applying the national patient safety goals when taking a verbal prescription for a client. Which of the following instruction should the nurse include? - ANS Read back the prescription to the provider. A nurse is participating in a community health screening. Which of the following information should the nurse include about the risk factors for breast cancer? - ANS The use of hormone replacement therapy increases the risk for breast cancer. A nurse is providing teaching to a client who has a prescription for risedronate to treat postmenopausal osteoporosis. Which of the following client statement indicating understanding of the teaching? - ANS I won't lie down for 30 minutes after I take my medication. A nurse is reviewing the urinalysis report for a client who reports to dysuria. Which of the following findings should the nurse identify as a manifestation of a urinary tract infection (UTI)? - ANS Presence of crystals. A nurse in a providers office is caring for a client who has a new prescription for opioids analgesic. The client states that they are concerned about developing constipation. Which of the following actions should the nurse take first? - ANS Identify the clients usual about illumination planner. A charge nurse is planning a presentation about electronica health record (EHR) for a group of newly licensed nurses. Which of the following information should a nurse include? - ANS Maintaining security of client information is a concern with EH ours. A nurse is planning to provide teaching for a client who has fibromyalgia and is experiencing chronic pain. The nurse should expect to teach the client about which of the following medications? - ANS Duloxetine. A nurse is reviewing the facility policy about occurrences that require an incident report with a newly licensed nurse. Which of the following examples should a nurse include? - ANS Omission of a laboratory test. A nurse is teaching a client to self administer eight units of NPH insulin and two units of regular insulin in the same syringe. Which of the following client statement indicating understanding of the teaching? - ANS I'll draw up regular insulin into the syringe before the NPH insulin. A home health nurse is making an initial visit to a client who reports fecal incontinence. Which of the following actions should the nurse take first? - ANS Ask questions about the clients typical dietary intake. A nurse is assisting a client who has been coughing frequently during meals. The nurse should initiate a referral to which of the following members of the intraprofessional team to evaluate the client for dysphasia? - ANS Speech language pathologist. A nurse is using the SOAP format to document in the electronica medical record for a client who is today's postoperative following an open cholecystectomy. Which of the following entries should the nurse place in the a portion of the SOAP progress note? - ANS Ineffective airway clearance due to inadequate use of spirometer. The nurse is caring for an unconscious client who has brought into the emergency apartment by alarm force meant agent. The law-enforcement agent request that the nurse obtain a blood sample for toxicity screening. Which of the following actions should the nurse take? - ANS Refuse to provide a blood sample. A nurse is obtaining signatures signatures on informed consent forms from a group of clients who are scheduled for surgery. Which of the following individuals should the nurse identify as legally unable to provide informed consent? - ANS A young adult who received morphine for pain. A nurse in a providers office is planning medication teaching for a client who has a urinary track infection. The nurse should prepare teaching for which of the following medications? - ANS Nitrofurantoin. A nurse is providing teaching to a group of newly licensed nurses about the legal scope of practice for nurses. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching? - ANS I can reposition a client who has tetraplegia without our providers prescription. A nurse is preparing to administer furosemide 35 mg IV to a client. The amount available is 10 mg/mL. How many milliliters should the nurse administer? - ANS 3.5 mL A nurse is teaching a client who has a new diagnosis of obstructive sleep apnea. Which of the following statements to the nurse include obstructive sleep apnea? - ANS occurs when you start breathing for at least 10 seconds.