RNSG 1430| RN CONCEPT BASED ASSESSMENT
LEVEL 1 NEWEST 2024 ACTUAL EXAM 100
QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES
(VERIFIED ANSWERS) |ALREADY
GRADED A+
A nurse is providing discharge teaching about nutrition
management to a client who has COPD. Which of the
following instructions should the nurse include in the
teaching? - ...ANSWER...Have a high-calorie protein drink
between meals.
RATIONALE: The nurse should encourage a client who has
COPD to drink a high-calorie protein drink between meals.
Anorexia is a manifestation of COPD and this added
nutritional intake promotes weight gain.)
A nurse is caring for a client who has dysphagia following a
stroke. Which of the following actions should the nurse take
to facilitate safe swallowing and decrease the risk of
aspiration? - ...ANSWER...Delay the clients meal-time if he
is fatigued.
RATIONALE: To facilitate safe swallowing and decrease the
risk of aspiration, the nurse should encourage the client to
test prior to meal-time. If the client is fatigued, the nurse
should delay the meal-time and give the client time to rest.)
A nurse is teaching the parent of a toddler about home injury
prevention. When discussing snacks, which of the following
,statements by the parent indicates an understanding of the
teaching? - ...ANSWER..."I can give her watermelon pieces
after I remove the seeds."
RATIONALE: The nurse should inform the parent that
toddlers can easily choke on seeds from fruits, such as
watermelon seeds or cherry pits, because of their round shape
and size. Removing the seeds and cutting the watermelon into
pieces provides the toddler with a nutritious snack that does
not increase the toddler's risk of foreign body obstruction.)
A nurse is asked by a provider to perform an invasive
procedure for which he has not received training. Which of
the following actions should the nurse take to ensure that it is
within his legal scope of practice to perform this procedure? -
...ANSWER...Check the states nurse practice act before
performing the procedure.
RATIONALE: The nurse should check the state's nurse
practice act to verify that performance is within his scope of
practice. This will ensure that the nurse follows legal
guidelines for his scope of practice. If the nurse works in more
than one state, he should check the nurse practice act for each
state, because guidelines for this procedure might differ from
state to state. If the procedure is within the nurse's scope of
practice, he should take necessary steps to gain competence in
the procedure before performing it on a client.)
A nurse is caring for a older adult client who has a leg
wound following a fall on the stairs. The nurse would
identify which of the following factors as an expected, age-
related change in older adults that can impair wound healing?
-
...ANSWER...Elastin fibers separate and thicken.
RATIONALE: The nurse should identify that elastin fibers in
an older adult client thicken and separate, which can cause
,delayed wound healing and lead to a "saggy" appearance due
to decreased skin elasticity.)
A nurse in a long-term care facility discovers a small fire in a
client's trash can. After moving the client to safety, which of
the following actions should the nurse take next? -
...ANSWER...Pull the alarm to notify emergency services.
RATIONALE: Evidence-based practice indicates the nurse
should first rescue and remove clients in immediate danger
and then activate the alarm to notify authorities of the
situation.)
A nurse is preparing to leave the room who is on isolation
precautions. Which of the following actions should the nurse
take when removing a tied surgical mask? -
...ANSWER...Remove the mask by securely holding the ties
and moving it away from the face.
RATIONALE: The nurse should untie the bottom strings and
then the top strings. Finally, while still holding the strings, the
nurse should remove the mask from her face. This action
prevents the nurse from touching the front of the mask, which
is contaminated.)
A nurse is searching electronic databases for clinical research
about behavioral indicators. Which of the following online
sources should the nurse select to research this infant care
issue? - ...ANSWER...Cumulative Index to Nursing and
Allied Health Literature (CINAHL)
RATIONALE: The nurse should select the Cumulative Index
to Nursing and Allied Health Literature (CINAHL) to locate
clinical research about health-related client care issues.
CINAHL is a cumulative index that the nurse can search
, electronically to locate reliable data related to the specific
topic being researched.)
A nurse is preparing to administer three medications to a
client who has an NG tube: a levothyroxine tablet, an
ibuprofen gel cap, and a delayed-release omeprazole capsule.
Which of the following actions should the nurse take? -
...ANSWER...Crush the levothyroxine tablet into a powder
and dissolve it into 30 mL of warm sterile water.
RATIONALE: The nurse should prepare simple tablets for
NG administration by crushing them into a fine powder and
dissolving them in at least 30 mL of warm sterile water. Cold
water can cause discomfort. Sterile water eliminates the
possible problem of chemicals in tap water interacting with
the medication.)
A nurse is planning care who has an indwelling urinary
catheter. Which of the following interventions include in the
plan to prevent the development of a catheter-associated
urinary tract infection (CAUTI)? - ...ANSWER...Secure the
catheter tubing to the client's leg.
RATIONALE: The nurse should assess the client's need for
urinary catheterization and should follow evidence-based
practice to prevent or reduce the risk of CAUTI development.
This includes securing the catheter tubing to the client's leg so
that the catheter does not move, reducing the risk of urethral
trauma and introduction of bacteria into the urinary system.)
A nurse is caring for a 2-year-old toddler who is immediately
postoperative. Which of the following pain scales should the
nurse use to access the toddler's pain level? -
...ANSWER...FLACC scale
LEVEL 1 NEWEST 2024 ACTUAL EXAM 100
QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES
(VERIFIED ANSWERS) |ALREADY
GRADED A+
A nurse is providing discharge teaching about nutrition
management to a client who has COPD. Which of the
following instructions should the nurse include in the
teaching? - ...ANSWER...Have a high-calorie protein drink
between meals.
RATIONALE: The nurse should encourage a client who has
COPD to drink a high-calorie protein drink between meals.
Anorexia is a manifestation of COPD and this added
nutritional intake promotes weight gain.)
A nurse is caring for a client who has dysphagia following a
stroke. Which of the following actions should the nurse take
to facilitate safe swallowing and decrease the risk of
aspiration? - ...ANSWER...Delay the clients meal-time if he
is fatigued.
RATIONALE: To facilitate safe swallowing and decrease the
risk of aspiration, the nurse should encourage the client to
test prior to meal-time. If the client is fatigued, the nurse
should delay the meal-time and give the client time to rest.)
A nurse is teaching the parent of a toddler about home injury
prevention. When discussing snacks, which of the following
,statements by the parent indicates an understanding of the
teaching? - ...ANSWER..."I can give her watermelon pieces
after I remove the seeds."
RATIONALE: The nurse should inform the parent that
toddlers can easily choke on seeds from fruits, such as
watermelon seeds or cherry pits, because of their round shape
and size. Removing the seeds and cutting the watermelon into
pieces provides the toddler with a nutritious snack that does
not increase the toddler's risk of foreign body obstruction.)
A nurse is asked by a provider to perform an invasive
procedure for which he has not received training. Which of
the following actions should the nurse take to ensure that it is
within his legal scope of practice to perform this procedure? -
...ANSWER...Check the states nurse practice act before
performing the procedure.
RATIONALE: The nurse should check the state's nurse
practice act to verify that performance is within his scope of
practice. This will ensure that the nurse follows legal
guidelines for his scope of practice. If the nurse works in more
than one state, he should check the nurse practice act for each
state, because guidelines for this procedure might differ from
state to state. If the procedure is within the nurse's scope of
practice, he should take necessary steps to gain competence in
the procedure before performing it on a client.)
A nurse is caring for a older adult client who has a leg
wound following a fall on the stairs. The nurse would
identify which of the following factors as an expected, age-
related change in older adults that can impair wound healing?
-
...ANSWER...Elastin fibers separate and thicken.
RATIONALE: The nurse should identify that elastin fibers in
an older adult client thicken and separate, which can cause
,delayed wound healing and lead to a "saggy" appearance due
to decreased skin elasticity.)
A nurse in a long-term care facility discovers a small fire in a
client's trash can. After moving the client to safety, which of
the following actions should the nurse take next? -
...ANSWER...Pull the alarm to notify emergency services.
RATIONALE: Evidence-based practice indicates the nurse
should first rescue and remove clients in immediate danger
and then activate the alarm to notify authorities of the
situation.)
A nurse is preparing to leave the room who is on isolation
precautions. Which of the following actions should the nurse
take when removing a tied surgical mask? -
...ANSWER...Remove the mask by securely holding the ties
and moving it away from the face.
RATIONALE: The nurse should untie the bottom strings and
then the top strings. Finally, while still holding the strings, the
nurse should remove the mask from her face. This action
prevents the nurse from touching the front of the mask, which
is contaminated.)
A nurse is searching electronic databases for clinical research
about behavioral indicators. Which of the following online
sources should the nurse select to research this infant care
issue? - ...ANSWER...Cumulative Index to Nursing and
Allied Health Literature (CINAHL)
RATIONALE: The nurse should select the Cumulative Index
to Nursing and Allied Health Literature (CINAHL) to locate
clinical research about health-related client care issues.
CINAHL is a cumulative index that the nurse can search
, electronically to locate reliable data related to the specific
topic being researched.)
A nurse is preparing to administer three medications to a
client who has an NG tube: a levothyroxine tablet, an
ibuprofen gel cap, and a delayed-release omeprazole capsule.
Which of the following actions should the nurse take? -
...ANSWER...Crush the levothyroxine tablet into a powder
and dissolve it into 30 mL of warm sterile water.
RATIONALE: The nurse should prepare simple tablets for
NG administration by crushing them into a fine powder and
dissolving them in at least 30 mL of warm sterile water. Cold
water can cause discomfort. Sterile water eliminates the
possible problem of chemicals in tap water interacting with
the medication.)
A nurse is planning care who has an indwelling urinary
catheter. Which of the following interventions include in the
plan to prevent the development of a catheter-associated
urinary tract infection (CAUTI)? - ...ANSWER...Secure the
catheter tubing to the client's leg.
RATIONALE: The nurse should assess the client's need for
urinary catheterization and should follow evidence-based
practice to prevent or reduce the risk of CAUTI development.
This includes securing the catheter tubing to the client's leg so
that the catheter does not move, reducing the risk of urethral
trauma and introduction of bacteria into the urinary system.)
A nurse is caring for a 2-year-old toddler who is immediately
postoperative. Which of the following pain scales should the
nurse use to access the toddler's pain level? -
...ANSWER...FLACC scale
