Rn Concept-Based Assessment Level 2
Online Practice B
A nurse is assessing a client for manifestations of left-sided heart failure. Which of the
following findings should the nurse expect?
A) Weight gain
B) Enlarged liver
C) Distended abdomen
D) Cool extremities - answerD (Cool extremities; Rationale: The nurse should expect to
find cool extremities in the client who has left-sided heart failure due to a decreased
cardiac output leading to impaired tissue perfusion.)
A nurse is assessing a 6-month-old infant who has bacterial pneumonia. Which of the
following manifestations should the nurse expect?
A) Protruding tongue
B) Facial flushing
C) Nasal flaring
D) Tympany with chest percussion - answerC (Nasal flaring; Rationale: Infants who
have bacterial pneumonia can exhibit manifestations such as nasal flaring and
retractions of the intercostal and sub-sternal spaces due to attempts to breathe in more
oxygen to compensate for hypoxia.)
A nurse is caring for a school-age child who was admitted to the emergency department
for acute asthma exacerbation. Which of the following actions should the nurse take
first?
A) Encourage the child to take frequent sips of cool fluids.
B) Apply humidified oxygen with a simple mask.
C) Start a peripheral access IV.
D) Administer an albuterol nebulizer treatment. - answerB (Apply humidified oxygen with
a simple mask; Rationale: The first action the nurse should take when using the airway,
breathing, and circulation approach to client care for a school-age child who is
experiencing acute asthma exacerbation is to apply humidified oxygen with a simple
mask. Humidified oxygen should be administered at a level to maintain oxygen
saturation above 90%.)
The nurse is providing teaching about foot care to a client who has diabetes mellitus.
Which of the following client statements indicates an understanding of the teaching?
A) "I'll wash my feet every day with soap and lukewarm water."
B) "I'll apply lotion to my feet daily, especially in between my toes."
C) "It's okay for me to go barefoot in the house, but not outside."
, D) "I'll soak my feet every morning before bedtime." - answerA ("I'll wash my feet every
day with soap and lukewarm water."; Rationale: The client should keep her feet clean to
prevent abrasions and infection. A client who has diabetic neuropathy has reduced
sensation in the feet. Therefore, the client should use an elbow or a thermometer to test
the temperature of the water and ensure that it is lukewarm. Hot water can irritate the
skin and lead to breakdown.)
A nurse is reviewing the medical record of a client who has decreased urinary output.
Which of the following findings should the nurse identify as a risk factor for the
development of pyelonephritis?
A) Diabetes mellitus
B) Radical prostatectomy 2 years ago
C) Cholelithiasis
D) Taking permethrin to treat pediculosis capitis - answerA (Diabetes mellitus;
Rationale: The nurse should identify that clients who have diabetes mellitus are at
increased risk for the development of pyelonephritis due to a loss of bladder tone as a
result of neuropathy, or from an ascending lower urinary tract infection caused by
glycosuria.)
A nurse is assessing a client who has acute cholecystitis. Which of the following
findings should the nurse expect? (Select all that apply.)
A) Fever
B) Dyspepsia
C) Pain radiating to the left shoulder
D) Blood-tinged stools
E) Eructation - answerA, B, E (Fever, Dyspepsia, Eructation; Rationale: Fever is correct.
The nurse should expect to find a fever in the client who has acute cholecystitis due to
the inflammatory process. Dyspepsia is correct. The nurse should expect to find
dyspepsia or indigestion in the client who has acute cholecystitis due to the biliary stasis
from conditions affecting the filling or emptying of the gallbladder. Eructation is correct.
The nurse should expect the client who has acute cholecystitis to exhibit eructation, or
belching, due to the biliary stasis from conditions affecting the filling or emptying of the
gallbladder.)
A nurse in an emergency department is caring for a client who has appendicitis. Which
of the following actions should the nurse take?
A) Restrict oral intake to clear fluids.
B) Place a heating pad on the client's abdomen.
C) Place the client in semi-Fowler's position.
D) Administer an enema. - answerC (Place the client in semi-Fowler's position;
Rationale: The nurse should place the client in semi-Fowler's position to contain
abdominal drainage in the lower abdomen and prevent it from seeping into the
peritoneum.)
A nurse is planning care for a client following collection of admission data. Which of the
following findings should the nurse identify as the priority client need?
Online Practice B
A nurse is assessing a client for manifestations of left-sided heart failure. Which of the
following findings should the nurse expect?
A) Weight gain
B) Enlarged liver
C) Distended abdomen
D) Cool extremities - answerD (Cool extremities; Rationale: The nurse should expect to
find cool extremities in the client who has left-sided heart failure due to a decreased
cardiac output leading to impaired tissue perfusion.)
A nurse is assessing a 6-month-old infant who has bacterial pneumonia. Which of the
following manifestations should the nurse expect?
A) Protruding tongue
B) Facial flushing
C) Nasal flaring
D) Tympany with chest percussion - answerC (Nasal flaring; Rationale: Infants who
have bacterial pneumonia can exhibit manifestations such as nasal flaring and
retractions of the intercostal and sub-sternal spaces due to attempts to breathe in more
oxygen to compensate for hypoxia.)
A nurse is caring for a school-age child who was admitted to the emergency department
for acute asthma exacerbation. Which of the following actions should the nurse take
first?
A) Encourage the child to take frequent sips of cool fluids.
B) Apply humidified oxygen with a simple mask.
C) Start a peripheral access IV.
D) Administer an albuterol nebulizer treatment. - answerB (Apply humidified oxygen with
a simple mask; Rationale: The first action the nurse should take when using the airway,
breathing, and circulation approach to client care for a school-age child who is
experiencing acute asthma exacerbation is to apply humidified oxygen with a simple
mask. Humidified oxygen should be administered at a level to maintain oxygen
saturation above 90%.)
The nurse is providing teaching about foot care to a client who has diabetes mellitus.
Which of the following client statements indicates an understanding of the teaching?
A) "I'll wash my feet every day with soap and lukewarm water."
B) "I'll apply lotion to my feet daily, especially in between my toes."
C) "It's okay for me to go barefoot in the house, but not outside."
, D) "I'll soak my feet every morning before bedtime." - answerA ("I'll wash my feet every
day with soap and lukewarm water."; Rationale: The client should keep her feet clean to
prevent abrasions and infection. A client who has diabetic neuropathy has reduced
sensation in the feet. Therefore, the client should use an elbow or a thermometer to test
the temperature of the water and ensure that it is lukewarm. Hot water can irritate the
skin and lead to breakdown.)
A nurse is reviewing the medical record of a client who has decreased urinary output.
Which of the following findings should the nurse identify as a risk factor for the
development of pyelonephritis?
A) Diabetes mellitus
B) Radical prostatectomy 2 years ago
C) Cholelithiasis
D) Taking permethrin to treat pediculosis capitis - answerA (Diabetes mellitus;
Rationale: The nurse should identify that clients who have diabetes mellitus are at
increased risk for the development of pyelonephritis due to a loss of bladder tone as a
result of neuropathy, or from an ascending lower urinary tract infection caused by
glycosuria.)
A nurse is assessing a client who has acute cholecystitis. Which of the following
findings should the nurse expect? (Select all that apply.)
A) Fever
B) Dyspepsia
C) Pain radiating to the left shoulder
D) Blood-tinged stools
E) Eructation - answerA, B, E (Fever, Dyspepsia, Eructation; Rationale: Fever is correct.
The nurse should expect to find a fever in the client who has acute cholecystitis due to
the inflammatory process. Dyspepsia is correct. The nurse should expect to find
dyspepsia or indigestion in the client who has acute cholecystitis due to the biliary stasis
from conditions affecting the filling or emptying of the gallbladder. Eructation is correct.
The nurse should expect the client who has acute cholecystitis to exhibit eructation, or
belching, due to the biliary stasis from conditions affecting the filling or emptying of the
gallbladder.)
A nurse in an emergency department is caring for a client who has appendicitis. Which
of the following actions should the nurse take?
A) Restrict oral intake to clear fluids.
B) Place a heating pad on the client's abdomen.
C) Place the client in semi-Fowler's position.
D) Administer an enema. - answerC (Place the client in semi-Fowler's position;
Rationale: The nurse should place the client in semi-Fowler's position to contain
abdominal drainage in the lower abdomen and prevent it from seeping into the
peritoneum.)
A nurse is planning care for a client following collection of admission data. Which of the
following findings should the nurse identify as the priority client need?
