Rn Concept-Based Assessment Level 2 Online Practice B

A nurse is reviewing the laboratory results of an adult male client who has hyperlipidemia and is making lifestyle changes to improve his cholesterol levels. Which of the following findings indicates to the nurse that the client had achieved a therapeutic response? A) LDL 168 mg/dL B) HDL 50 mg/dL C) Total Cholesterol 268 mg/dL D) Triglycerides 250 mg/dL

B (HDL 50 mg/dL; Rationale: This finding indicates that the client has achieved a therapeutic response from a lifestyle change because the HDL is within the expected reference range of greater than 45 mg/dL for an adult male client.)

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? A) "Wear open-toe shoes to allow air to circulate around your feet." B) "Use a heating pad set on low to warm your feet when they feel cold." C) "File your toenails straight across to prevent ingrown toenails." D) "Apply a thin layer of lotion between your toes twice per day."

C ("File your toenails straight across to prevent ingrown toenails."; Rationale: The nurse should instruct the client to file toenails straight across. If the client's toenails are rounded during clipping, the client is at risk for developing ingrown toenails, increasing the risk for infection.)

A nurse is assessing a 6-month-old infant who has gastroenteritis with mild dehydration. Which of the following findings should the nurse expect? A) Absence of tears when crying B) Loss of 6% of body weight C) Sunken anterior fontanel D) Capillary refill greater than 2 seconds

D (Capillary refill greater than 2 seconds; Rationale: The nurse should expect an infant who has mild dehydration to have a capillary refill time of greater than 2 seconds. Other manifestations of mild dehydration include slight thirst, decreased urine output, and moist mucus membranes.)

A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take? A) Distract the client by having him complete a puzzle. B) Encourage the client to take a deep breath every 2 seconds. C) Administer methylphenidate to the client. D) Stay with the client until manifestations subside.

D (Stay with the client until manifestations subside. Rationale: The nurse should stay with the client during a panic attack until manifestations subside and the client is reoriented to reality. This ensures the client's safety and conveys concern to the client.)

A nurse is preparing to mix NPH insulin and insulin aspart in a single syringe for a client who has type 2 diabetes mellitus. Identify the sequence the nurse should follow. A) Inject air into the vial equal to amount of insulin aspart prescribed. B) Withdraw the prescribed volume of insulin aspart into the syringe. C) Inject air into the vial equal to the amount of NPH insulin prescribed. D) Withdraw the prescribed volume of NPH insulin into the syringe.

The nurse should always withdraw short-acting insulin before long-acting insulin to avoid contaminating the short-acting vial. The nurse should first prepare the NPH insulin vial by filling the syringe with air equal to the amount prescribed and injecting it into the NPH vial. Then, the nurse should prepare the insulin aspart vial by filling the syringe with air equal to the amount prescribed and inject it into the insulin aspart vial. With the syringe still in the insulin aspart vial, the nurse should withdraw the correct dose of medication into the syringe. Finally, the nurse should withdraw the correct dose of NPH insulin into the syringe.

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? A) The client requests to see a priest for spiritual guidance. B) The client reports coughing and a change of voice whenever he eats. C) The client reports pain immediately following physical therapy. D) The client is worried about financially supporting his family because of his illness.

B (The client reports coughing and a change of voice whenever he eats; Rationale: When using Maslow's hierarchy of needs, the nurse should determine that the priority finding is the client's physiological needs, such as coughing and a change of voice whenever he eats. This finding indicates a risk for aspiration, which can impair the client's breathing and oxygenation status. Difficulty eating also creates an impairment of nutrition. Breathing, oxygenation, and nutrition are all physiological needs. Therefore, the nurse should identify this finding as the priority client need.)

A nurse is providing teaching about home care to the parent of an adolescent who has infectious mononucleosis. Which of the following manifestations should the nurse instruct the parent to report to the provider? A) Swollen cervical lymph nodes B) Exudate on tonsils C) Lack of energy D) Onset of abdominal pain

D (Onset of abdominal pain; Rationale: The nurse should instruct the parent to report the onset of abdominal pain to the provider because this is an indication of splenomegaly. Splenic hemorrhage or rupture can occur and is usually caused by trauma.)

A nurse is providing dietary teaching to a client who is at 13 weeks of gestation and has hyperemesis gravidarum. Which of the following statements should the nurse make? A) "Drink fluids between, rather than with, meals." B) "Eat food that are served warm." C) "Do not go more than 6 hr between meals." D) "Have a low-protein snack at bedtime."

A ("Drink fluids between, rather than with, meals."; Rationale: The nurse should instruct the client to avoid drinking fluids with meals because this can increase nausea. The client should separate solid food from liquids.)

A nurse is providing teaching about home care with an adolescent client who has a skin infection caused by methicillin - resistant Staphylococcus aureus (MRSA). Which of the following client statements indicates an understanding of the teaching? A) "I will soak in a bathtub filled one-forth of water with one-half cup of bleach." B) "I will wash my clothes in cold water and detergent." C) "I will throw away my razor after using it three times." D) "I will apply imiquimod cream to the lesions before going to bed each night."

A ("I will soak in a bathtub filled one-forth of water with one-half cup of bleach."; Rationale: The client should soak for at least 5 min in a bathtub filled one-fourth full of water with ½ cup of bleach once or twice per week. This will help prevent reoccurrence of the infection.)

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."

A ("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

A (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 developing a plan of care for a client who is 1 hour postoperative following open carpal tunnel release to treat a musckuloskeletal injury. Which of the following interventions should the nurse include in the plan? A) Elevate the client's arm above the heart. B) Apply heat to the client's surgical site. C) Instruct the client to avoid moving their fingers. D) Monitor the client's ability to complete wrist range-of motion.

A (Elevate the client's arm above the heart.; Rationale: The nurse should elevate the client's arm and hand following carpal tunnel release to minimize swelling of the surgical site and decrease discomfort.)

A nurse is assessing for adverse medication reactions with a client who reports taking more than the recommended doses of acetaminophen for the management of chronic pain. Which of the following findings should the nurse identify as an adverse effect of acetaminophen? A) Elevated aspartate aminotransferase levels B) Decreased skin turgor C) Elevated WBC count D) Decreased audio acuity

A (Elevated aspartate aminotransferase levels; Rationale: The nurse should identify that an elevated aspartate aminotransferase (AST) is an indication of liver injury, which is an adverse effect of excessive doses of acetaminophen. In addition to elevated liver enzymes, other indications of liver injury include diaphoresis, nausea and vomiting, abdominal pain, and diarrhea.)

A nurse is monitoring a client who has metabolic acidosis due to salicylate overdose. For which of the following findings should the nurse monitor? A) Flushed, dry skin B) Seizures C) Hyperreflexia D) Positive Trousseau's sign

A (Flushed, dry skin; Rationale: The nurse should monitor a client who has metabolic acidosis for manifestations of warm, flushed, and dry skin due to vasodilation from an increased respiratory rate and the loss of CO2.)

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? A) Inaudible lung sounds B) Persistent cough C) Yellow zone peak flow meter reading D) Prolonged expiration phase

A (Inaudible lung sounds; Rationale: When using the airway, breathing, and circulation approach to client care, the nurse determines the priority finding is inaudible lung sounds on auscultation. Shortness of breath with an absence of lung sounds and increased respiratory rate indicates impending respiratory failure and asphyxia.)

A nurse is assessing a client who is experiencing diarrhea and vomiting and has a sodium level of 124 mEq/L. Which of the following manifestations should the nurse expect? A) Orthostatic hypotension B) Hoarse voice C) Neck vein distention D) Muscle twitching

A (Orthostatic hypotension; Rationale: The nurse should monitor the client who has a sodium level of 124 mEq/L for orthostatic hypotension. The expected reference range for sodium is 136 to 145 mEq/L. Other manifestations of hyponatremia include decreased deep tendon reflexes, headache, confusion, and lethargy.)

A nurse is caring for a client who is experiencing an asthma attack. Which of the following procedures should the nurse use to assess the client's respiratory status? A) Peak expiratory flow meter testing B) Spirometry monitoring C) Pulmonary functioning testing D) Chest x-ray

A (Peak expiratory flow meter testing; Rationale: The peak expiratory flow meter provides a means of evaluating the maximum flow of air the client expels during forceful exhalation. It provides information on how well asthma is being controlled as a part of daily monitoring and can be used when a client is having an asthma attack. The flow meter testing helps to gauge the peak-expiratory zone the client is experiencing and determines if the client should use immediate-acting bronchial dilator inhalers or seek emergency help.)

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? A) Place the client in high-Fowler's position B) Encourage the client to perform diaphragmatic breathing. C) Instruct the client to perform a huff-coughing technique. D) Administer a nebulized bronchodilator.

A (Place the client in high-Fowler's position; Rationale: According to evidence-based practice, the first action the nurse should take is to place the client in an upright, or high-Fowler's, position to facilitate ease of breathing.)

A nurse is assessing a client whose parent recently died. The nurse should identify that which of the following findings places the client at risk for maladaptive grieving? A) The client lost his house in a house fire 1 month ago. B) The client has retired after 30 years of employment. C) The client's parent was an older adult D) The client's parent had a chronic terminal illness.

A (The client lost his house in a house fire 1 month ago; Rationale: The nurse should identify that cumulative losses, the situational loss of a house unexpectedly due to a fire, combined with the loss of a family member, increases the client's risk for maladaptive grieving.)

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

A, 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 is planning discharge teaching for the parent of a newborn. Which of the following information should the nurse include? A) "Cover your newborn with a light blanket while she is sleeping." B) "Do not bathe your newborn immediately after she eats." C) "Place your newborn in a crib with a bumper pad." D) "Wash your newborn's face with a mild soap."

B ("Do not bathe your newborn immediately after she eats."; Rationale: The nurse should instruct the parent to avoid bathing the newborn immediately following a feeding to decrease the risk of regurgitation. The parent should bathe the newborn every 2 to 3 days.)

A nurse is providing teaching about home care with the parent of a child who has scabies. Which of the following statements by the parent indicates an understanding of the teaching? A) "I should apply the cream only to the areas where there is a rash." B) "I should wash my child's bed linens and clothing in hot water and detergent." C) "I should expect my child's rash to go away within 72 hours after starting treatment." D) "I should leave the cream on my child for 4 hours before washing it off."

B ("I should wash my child's bed linens and clothing in hot water and detergent."; Rationale: The parent should wash the child's clothing and bed linens in hot water and detergent, and dry all articles in a clothes dryer on the highest heat setting. This will kill the mites and prevent transmission of the infestation.)

A nurse is caring for a group of clients. Which of the following clients should the nurse identify as being at risk for developing respiratory acidosis? A) A client who has a fever B) A client who has abdominal ascites C) A client who is anxious D) A client who is receiving nasogastric suctioning

B (A client who has abdominal ascites; Rationale: The nurse should identify that a client who has abdominal ascites can experience a restriction of chest expansion, which impairs gas exchange and places the client at an increased risk for developing respiratory acidosis.)

A nurse is reviewing the laboratory records of a client who has AIDS. Which of the following laboratory results should the nurse review to determine if the client is at risk for malnutrition? A) WBC count B) Albumin level C) CD4 T cell count D) C-reactive protein level

B (Albumin level; Rationale: The nurse should review albumin levels to determine a client's risk for malnutrition. A client who is malnourished will have an albumin level below the expected reference range of 3.5 to 5 g/dL.)

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.

B (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%.)

A nurse is reviewing the laboratory results of a client who is scheduled for surgery and notes a potassium level of 6 mEq/L. Which of the following ECG findings should the nurse expect? A) Heart rate 64/min B) Tall T waves C) Shortened PR interval D) QRS 0.08 seconds

B (Tall T waves; Rationale: The nurse should identify that a potassium level of 6 mEq/L is above the expected reference range of 3.5 to 5 mEq/L, indicating that the client has hyperkalemia. Tall T waves are a manifestation of hyperkalemia when the potassium level is greater than 6 mEq/L, which can affect the myocardium and impact the client's surgical risk. The nurse should report this elevated potassium level to the provider.)

A nurse is assessing a client who has acute pyelonephritis. Which of the following findings should the nurse expect? A) Pain with palpitation to the sub-sternal notch B) Urinary burning C) Ecchymosis over the flank D) Radiating pain to the right shoulder

B (Urinary burning; Rationale; A client who has acute pyelonephritis can experience burning, frequency, and urgency with urination.)

A nurse is providing discharge teaching to the parents of a newborn about crib use. Which of the following statements should the nurse make? A) "Arranging small stuffed animals in the crib is recommended to provide a feeling of security for your baby." B) "Moving the crib near a window in the nursery will provide your baby with necessary fresh air and natural light." C) "Dressing your baby in a one-piece sleeper for bedtime will replace the need to use a blanket or a sheet." D) "Placing your baby on her tummy in the crib will hasten drowsiness and provide a more restful night's sleep."

C ("Dressing your baby in a one-piece sleeper for bedtime will replace the need to use a blanket or a sheet." Rationale: The nurse should instruct the parents to dress the newborn in a one-piece sleeper or a "sleep-sack" at bedtime, which keeps the newborn's body covered. Blankets and quilts significantly increase the newborn's risk of suffocation and should be avoided.)

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? A) "Decrease your calcium intake." B) "You should consume at least 2,400 milligrams of salt per day." C) "Limit the amount of spinach in your diet." D) "Increase your fluid intake to one and a half liters daily."

C ("Limit the amount of spinach in your diet."; Rationale:The nurse should instruct the client to decrease intake of foods that contain oxalates. Restricting foods that are high in oxalates, such as spinach, tea, nuts, chocolate, and strawberries, can decrease the risk of further calculi formation.)

A nurse is assessing a client who has hypermagnesemia. Which of the following manifestations should the nurse expect? A) Hyperactive deep tendon reflexes B) Abdominal distention C) Bradycardia D) Positive Trousseau's sign

C (Bradycardia; Rationale: The nurse should expect to find bradycardia in a client who has hypermagnesemia, as well as other cardiac manifestations, including peripheral vasodilation and hypotension due to a reduced membrane excitability. Clients who have severe hypermagnesemia are at an increased risk for cardiac arrest.)

A nurse is assessing a client who has peripheral arterial disease. Which of the following findings should the nurse expect? A) Brown discoloration of the lower extremities B) Superficial ulcer on the medial aspect of the ankle C) Dependent rubor D) Telangiectasias

C (Dependent rubor; Rationale: The nurse should expect redness to the lower extremities, or dependent rubor, when the client's legs are dangling or in a dependent position.)

A nurse is caring for a client who has respiratory acidosis due to opioid over-sedation. Which of the following actions should the nurse take first? A) Place the client on mechanical ventilation. B) Apply oxygen using a rebreather oxygen mask. C) Ensure a patent airway using a chin-lift maneuver. D) Administer a reversal agent to the client.

C (Ensure a patent airway using a chin-lift maneuver; Rationale: The first action the nurse should take when using the airway, breathing, and circulation approach to client care is to open the client's airway by performing a chin-lift maneuver.)

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

C (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 assessing a client for manifestations of heat stroke. Which of the following findings should the nurse expect? A) Hypertension B) Somnolence C) Oliguria D) Bradycardia

C (Oliguria; Rationale: A client who has heat stroke will manifest a body temperature of 40° C (104° F) or greater, which can lead to dehydration and oliguria. Complications include multiple organ dysfunction syndrome, which includes renal impairment. The nurse should closely monitor the client's urine output and specific gravity to assist with determining fluid needs.)

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.

C (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 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? A) "Administer the medication into your child's abdomen" B) "Expect your child to sleep for several hours after receiving the medication." C) "Place your child's unused extra syringes in the refrigerator for storage." D) "Give a second injection if the first fails to reverse your child's symptoms."

D ("Give a second injection if the first fails to reverse your child's symptoms." Rationale: The nurse should instruct the parent to administer a second dose, using a second auto-injector, if the first dose doesn't completely reverse the child's allergic reaction. The effects of the medication will begin to fade in 20 min. However, the child should be transported to the nearest hospital immediately because hospitalization for a few hours following administration of the injection is recommended. The nurse should instruct the parent to bring the auto-injector with the child to the hospital.)

A nurse is providing teaching about home care to the parent of a child who has pediculosis capitis. Which of the following information should the nurse include? A) Soak the child's combs and brushes in hot water for 5 min. B) Rinse the child's hair each day with 236.5 mL (1 cup) of vinegar. C) Seal the child's nonwashable toys in plastic bags for 7 days. D) Comb the child's hair daily with an extra fine-tooth comb.

D (Comb the child's hair daily with an extra fine-tooth comb; Rationale: The nurse should instruct the parent to remove nits from the child's hair each day by combing her hair with an extra fine-tooth comb. The parent can also remove nits with tweezers or fingernails.)

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

D (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 client who has an external fixator to the right lower arm following musculoskeletal trauma. Which of the following findings should indicate to the nurse that the client has developed compartment syndrome? A) Serous drainage is present on the pin site dressings B) Flushing of the skin on the right arm C) Bounding pulse palpated in the radial artery D) Numbness to the fingers on the right arm

D (Numbness to the fingers on the right arm; Rationale: The nurse should identify a decrease in sensation, such as numbness and tingling of the fingers, as one of the first indications that the client might be developing compartment syndrome of the right lower arm. Compartment syndrome is the result of edema and ischemia, a complication following musculoskeletal injury. Other manifestations include increased pain, paralysis, pallor, and decreased or absent pulses.)

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? A) Polyethylene glycol B) Bumetanide C) Loperamide D) Ondansetron

D (Ondansetron; Rationale: The nurse should anticipate administering ondansetron to the toddler. Ondansetron is administered to toddlers who have gastroenteritis and dehydration to decrease the episodes of emesis and to help eliminate the need for intravenous fluids.)