RN Concept-Based Assessment Level 2 Online Practice B

A nurse is caring for a client who has possible appendicitis. Which of the following actions should the nurse take?

Start IV fluid replacement

A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take?

Stay with the client until manifestations subside

A nurse is assessing a client who has deep-vein thrombosis (DVT) in the right lower extremity. Which of the following findings on the affected extremity should the nurse expect?

Swelling

A nurse is assessing a client whose parents recently died. The nurse should identify that which of the following findings places the client at risk for maladaptive grieving?

The client lost his house in a house fire 1 month ago

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?

The client reports coughing and a change of voice whenever he eats

A nurse is teaching about clonazepam with a young adult female client who has generalized anxiety disorder. Which of the following statements should the nurse include in the teaching?

This medication could cause you to have thoughts of self-harm

A nurse is assessing a client who has developed Clostridium difficile as an adverse effect to ciprofloxacin. Which of the following medications should the nurse expect the provider to prescribe to treat the C. difficile?

Vancomycin

A hospice nurse is visiting with a client following the death of her partner 1 month ago. The client is tearful and states she does not see how she can ever be happy again. Which of the following responses should the nurse make?

What are some of the best times with your partner that you remember?

A nurse is providing dietary teaching to a client who is at 13 weeks gestation and has hyperemesis gravidarum. Which of the following statements should the nurse make?

drink fluids between, rather than with, meals

A nurse is assessing a 6-month-old infant who has bacterial pneumonia. Which of the following manifestations should the nurse expect?

nasal flaring

A nurse is providing teaching to a client who has osteoporosis. Which of the following information should the nurse include in the teaching?

perform exercises to strengthen the abdominal core

A home health nurse is assessing a client who has COPD. The client has a respiratory rate of 22/min and reports shortness of breath. Which of the following actions should the nurse take first?

place the client in high-Fowler's position

A nurse is reviewing the laboratory results of a client who is receiving gentamicin for the treatment of an infection related to renal calculi. Which of the following findings should the nurse report immediately to the provider?

Creatinine 2.5 mg/dL

A nurse is planning discharge teaching for the parent of a newborn. Which of the following information should the nurse include?

Do not bathe your newborn immediately after she eats

A nurse is providing discharge teaching to the parents of a newborn about crib use. Which of the following statements should the nurse make?

Dressing your baby in a one-piece sleeper for bedtime will replace the need to use a blanket or a sheet

A 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?

I'll wash my feet everyday with soap and lukewarm water

A nurse is reviewing a client's medical record prior to a laparoscopic appendectomy. Which of the following findings should the nurse report to the provider?

Report of urinating small amounts twice daily

A nurse in an emergency department is reviewing the laboratory report of a client who has hyperventilation. The client's ABG results are pH 7.50, PaCO2 29 mmHg, and HCO3 25 mEq/L. The nurse should interpret that these values are an indication of which of the following acid-base imbalances?

Respiratory alkalosis

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?

Apply humidified oxygen with simple mask

A nurse in an emergency department is assessing a client who displays manifestations of a small bowel obstruction. Which of the following findings should the nurse expect? Select all that apply

Abdominal distention, vomiting, hyperactive bowel sounds

A nurse is assessing a newly admitted client who has an intense fear of heights. Which of the following clinical names for this fear should the nurse document in the client's medical record?

Acrophobia

A nurse a reviewing the laboratory report of a client who is taking atorvastatin. Which of the following findings should the nurse identify as an indication that the medication is having an adverse effect?

Aspartate aminotransferase (AST) 45 units/L

A nurse is assessing a preschool-age child who has chickenpox. The parent asks the nurse how to treat the child's fever. Which of the following responses should the nurse make?

Avoid giving aspirin to your child

A nurse is developing a plan of care for a client who is scheduled to have an induction of labor due to a fetal demise. Which is the following actions should the nurse include?

Bathe, diaper, and dress the child before bringing the newborn to the client

A nurse in a provider's office is assessing a client who is taking warfarin to treat atrial fibrillation. Which of the following findings should the nurse identify as an adverse effect that should be reported to the provider?

Black, tarry stools

A nurse is assessing a client who has hypermagnesemia. Which of the following manifestations should the nurse expect?

Bradycardia

A nurse is assessing a 6-month-old infant who has gastroenteritis with mild dehydration. Which of the following findings should the nurse expect?

Capillary refill greater than 2 seconds

A nurse is assessing a client who has a new diagnosis of hypothyroidism. Which of the following manifestations should the nurse expect?

Cold intolerance

A nurse is assessing a client who is receiving intravenous medications. Which of the following findings should the nurse identify as a manifestation of respiratory acidosis?

Confusion

A nurse on a pediatric unit is preparing an in-service for coworkers about failure to thrive in infants. Which of the following risk factors should the nurse include?

Congenital heart disease

A nurse is caring for a client who has severe hypothermia. Which of the following actions should the nurse take?

Contact a specialized team to place the client on cardiopulmonary bypass

A nurse is developing a plan of care for a client who is 1 hr postoperative following open carpal tunnel release to treat a musculoskeletal injury. Which of the following interventions should the nurse include in the plan?

Elevate the client's arm above the heart

A nurse is caring for a client who has respiratory acidosis due to opioid oversedation. Which of the following actions should the nurse take first?

Ensure a patent airway using a chin-lift maneuver

A nurse is caring for a client who has generalized anxiety disorder. Which of the following medications should the nurse plan to administer?

Escitalopram

A nurse is teaching a client who has a new diagnosis of peripheral neuropathy about foot care. Which of the following statements should the nurse include?

File your toenails straight across to prevent ingrown toenails

A nurse is providing teaching to the parent of a school-age child who has a severe bee allergy and a new prescription for an epinephrine auto-injector. Which of the following instructions should the nurse include?

Give a second injection if the first fails to reverse your child's symptoms

A nurse is conducting a visual assessment for a client who is at risk for developing glaucoma. Which of the following findings should the nurse identify as a risk factor for this condition?

Heredity

A nurse is preparing to administer medication to a client who has a history of hypertension. The nurse should identify that which of the following is administered for antihypertensive therapy?

Hydrochlorothiazide

A nurse is reviewing the medical record of a client who has age-related macular degeneration (AMD). Which of the following findings should the nurse identify as a risk factor for this visual impairment?

Hypertension

A nurse is caring for a client who is experiencing a hyperglycemic-hyperosmolar state related to complications of diabetes mellitus. Which of the following findings should the nurse expect?

Hypotension

A nurse is assessing a client who has generalized anxiety disorder and has been practicing adaptive use of coping mechanisms. Which of the following responses indicates the client's adaptive use of suppression?

I avoid thinking about problems that worry me until I have time to focus on a solution

A nurse is providing teaching for a client following cataract surgery. Which of the following statements indicates to the nurse that the client understands the teaching?

I should avoid using the vacuum cleaner for several weeks

A nurse is providing discharge teaching for a client who has a new diagnosis of COPD. Which of the following client statements indicates an understanding of the teaching?

I will breathe out slowly through pursed lips if I feel short of breath

A nurse is assessing a school-age child who has asthma and shortness of breath. Which of the following assessment findings should the nurse identify as the priority?

Inaudible lung sounds

A nurse is admitting an infant who has pertussis. Which of the following actions should the nurse take?

Initiate droplet precautions for the infant

A nurse is providing teaching to a client who has calcium oxalate renal calculi. Which of the following statements should the nurse include in the teaching?

Limit the amount of spinach in your diet

A nurse is teaching a group of newly licensed nurses about risk factors for peptic ulcers. Which of the following risk factors should the nurse include in the teaching?

Long-term use of NSAIDs

A nurse is assessing a client for manifestations of heat stroke. Which of the following findings should the nurse expect?

Oliguria

A nurse is assessing an 18-month-old toddler who has gastroenteritis with dehydration. The toddler is able to consume 3 mL of oral rehydration solution every 5 min but still has emesis and diarrhea. Which of the following medications should the nurse anticipate administering to the toddler?

Ondansetron

A nurse is caring for a client who has right-sided hemiparesis following a stroke. Which of the following images is an indication that the nurse is correctly assisting the client to ambulate?

One hand on gait belt walking behind the patient on affected side (right side)

A nurse is teaching a client who has hypokalemia about nutrition management. Which of the following fruits should the nurse recommend as the best source of potassium?

One small orange

A nurse is assessing a client who has musculoskeletal trauma following a motor-vehicle crash 2 days ago. Which of the following findings should the nurse report to the provider?

Pain report

A nurse is assessing a client in the triage room of an emergency department. Based on the client findings, which of the following actions should the nurse take?

Place a surgical mask on the client

A nurse is teaching a group of newly licensed nurses about hypothermia and the care of a client who has frostbite to the fingers and toes from cold exposure. Which of the following information should the nurse include in the teaching about frostbite?

Place the affected areas of frostbite in a warm water bath

A nurse is reviewing the laboratory results of an adult client who has metabolic alkalosis. Which of the following findings should the nurse expect?

Potassium 3 mEq/L

A nurse is caring for a client who has deep vein thrombosis and is receiving heparin via continuous IV infusion. The client has a positive fecal occult blood test and abdominal tenderness upon palpation. Which of the following prescription should the nurse expect the provider to prescribe?

Protamine sulfate