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Rn Concept-Based Assessment exam level 2
(proctored)2024/2025 Question and Answer
100% GRADED A
A nurse is planning care for a client who has renal calculi. Which of the following interventions should the nurse include to promote elimination of the calculi? Maintain bedrest until calculi are expelled. Withhold thiazide diuretics. Encourage intake of at least 3 L of fluid each day. Collect all urine for 24 hr in a collection container. Encourage intake of at least 3 L of fluid each day. The nurse should encourage the client to consume at least 3 L of fluid each day. Increased fluid intake increases urine production, promotes eliminiation of calculi, and helps prevent recurrence. A nurse is providing postoperative education for a client following a laparoscopic cholecystectomy for cholelithiasis. Which of the following client statements indicates an understanding of the teaching?
"The adhesive bandages on my incision will fall off as the incision heals." "I will be able to take a shower in 1 week." "I will need to follow a liquid diet for the first 3 days after surgery." "I can begin to resume my normal activity level in 2 weeks." "The adhesive bandages on my incision will fall off as the incision heals." The nurse should instruct the client that the small adhesive bandages will lose their adhesiveness in 7 to 10 days. The client can then remove the bandages or allow the bandages to fall off over time as the incision heals. A nurse is planning care to prevent hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA) infection for a client who is immunocompromised. Which of the following interventions should the nurse include to prevent this antibiotic-resistant infection? Initiate contact precautions for this client. Bathe the client with chlorhexidine wipes. Administer ceftaroline to the client as a prophylactic measure. Avoid using alcohol-based hand sanitizers after caring for the client
The nurse should expect a client who has Graves' disease, an autoimmune form of hyperthyroidism, to experience exophthalmos, which is protrusion of the eyeballs. A nurse is teaching an older adult client who has peripheral neuropathy about a new prescription for duloxetine. Which of the following client statements indicates an understanding of the teaching? "It might take several weeks to notice an improvement in my symptoms." "I will need to take this medication on an empty stomach." "I should take a daily ibuprofen for generalized aches." "I will need to decrease my dietary sodium intake while taking this medication." It might take several weeks to notice an improvement in my symptoms." The nurse should instruct the client that duloxetine can take several weeks to be effective. This medication is an antidepressant that reduces the discomfort of peripheral neuropathy. A nurse is teaching a client who has scabies about a new prescription for lindane lotion. Which of the following client statements indicates an understanding of the treatment for this parasitic infection?
"I will apply the lotion once a day for 1 week." "I will rub in the lotion thoroughly from my face to my toes." "I will wash the lotion off 12 hours after I apply it." "I should avoid bathing for 6 hours prior to applying the lotion." "I will wash the lotion off 12 hours after I apply it." The nurse should instruct the client to apply the lotion and leave it in place for 8 to 12 hr and then remove it by washing it off. A nurse is assessing a client who has appendicitis. Which of the following findings should the nurse report to the provider immediately? WBC 16,000/mm³ Board-like abdomen Nausea and vomiting Temperature of 38° C (100.4° F) Board-like abdomen
"I will stop taking the medication immediately if I experience nausea." "I should contact my provider if I notice a pink-tinged color to my urine." "I will increase my dietary intake of spinach." "I will not be able to use an electric razor while I am taking this medication." "I should contact my provider if I notice a pink-tinged color to my urine." The nurse should instruct the client to monitor for blood in the urine. The client should report a pink-tinged urine color to the provider. A nurse is reviewing the urinalysis results of a client who has completed a 14-day course of ciprofloxacin to treat pyelonephritis. Which of the following values should indicate to the nurse that the client has a continuing infection? Negative nitrites RBCs < 2 Positive leukocyte esterase Amber-colored urine Positive leukocyte esterase
The nurse should identify that a positive leukocyte esterase test is an indication of the presence of WBCs in the urine and the presence of continued infection. A nurse is assessing a client for manifestations of grief after having a colostomy for removal of colon cancer. Which of the following findings indicates to the nurse that the client has accepted the loss? Becomes angry when it is time to perform colostomy care Touches the colostomy stoma when the bag is changed Looks away as the nurse empties the colostomy bag Tells others that it will be nice to have a normal bowel movement again Touches the colostomy stoma when the bag is changed The client touching the colostomy stoma when the bag is changed should indicate to the nurse that the client is accepting and coping with the alteration of body image and has gone through the stages of grief. A nurse is assessing a school-age child who has appendicitis with possible perforation. Which of the following findings should the nurse identify as a manifestation of peritonitis?
When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding to report to the provider is the hemoglobin below the expected reference range, which in an indication of a peptic ulcer that is chronically bleeding. A nurse in an emergency department is assessing a client who has hyperthermia. Which of the following findings should the nurse identify as an indication that the client has heat exhaustion? Hallucinations Vomiting Bradycardia Seizures Vomiting The nurse should identify that heat exhaustion is usually the result of excess sweating, leading to dehydration. Manifestations include nausea, vomiting, headache, dizziness, fainting, and a temperature typically between 38.3º C and 38.9º C (101º F and 102º F). A nurse is providing teaching to a client who is experiencing malabsorption related to lactose intolerance. Which of the following foods should the nurse recommend to the client as the best nondairy source of calcium?
Ground beef Collard greens Cauliflower Walnuts Collard greens The nurse should determine that collard greens are the best food source to recommend because 1 cup contains 268 mg of calcium per serving. A nurse is planning care for a client who is postoperative and has developed left lower leg deep- vein thrombosis. Which of the following interventions should the nurse include in the plan of care? Initiate complete bed rest. Massage the left lower leg three times a day. Make sure the client's legs are elevated while in bed. Apply cold compresses to the left lower leg every 2 hr.
A nurse is developing a plan of care for a preschooler who has heart failure. Which of the following interventions should the nurse include in the plan? Assess and record the child's blood pressure every 6 to 8 hr. Weigh the child once each week using the same scale. Place the child in a supine position for a minimum of 4 hr each day. Offer small, frequent meals based on the child's endurance level. Offer small, frequent meals based on the child's endurance level. The nurse should offer small, frequent meals based on the child's endurance level. The child requires an increase in caloric intake, but often has a low energy level. The nurse should choose times for meals when the child is most rested, and make sure those meals are high in calories. A nurse in an emergency department is caring for a client who has heat stroke. Which of the following actions should the nurse take to treat this form of hyperthermia? Apply ice packs to the client's axillae, neck, groin, and chest. Administer aspirin to the client Initially offer the client cool, oral fluids.
Continue cooling measures until the client's rectal temperature is 37.2º C (99º F). Apply ice packs to the client's axillae, neck, groin, and chest. The nurse should recognize that treatment for heat stroke involves cooling the client's core body temperature quickly. The nurse should apply ice to the client's axillae, neck, groin, and chest while also spraying the client's body with tepid water. A nurse is teaching a client who has asthma about medications to treat an acute asthma attack. Which of the following medications should the nurse include in the teaching? Fluticasone Salmeterol Albuterol Montelukast Albuterol Albuterol is a short-acting beta agonist that causes bronchodilation. The client should use albuterol during asthma attacks and before engaging in activities that are likely to cause an attack. The nurse should instruct the client to keep an albuterol inhaler with him at all times.
A nurse is providing teaching to a client who has diabetes mellitus and a new prescription for extended-release metformin. Which of the following client statements indicates an understanding of the teaching? "I will avoid drinking grapefruit juice." "I will chew the medication if I can't swallow it whole." "I will call the doctor if I have muscle pain in my back." "I will take this medication on an empty stomach." "I will call the doctor if I have muscle pain in my back." Metformin, a biguanide, can cause lactic acidosis, which is a life-threatening complication manifesting as muscle aches, sleepiness, malaise, and hyperventilation. If these manifestations develop, the client should stop taking the medication and notify the provider immediately. A nurse is teaching a client who has hypertension and a new prescription for atenolol. Which of the following information should the nurse include in the teaching? "If you miss a dose, you should take two doses the next morning." "You should stop taking this medication immediately if you experience depression." "You might experience an increased sensitivity to heat while taking this medication."
"You should contact your provider if your pulse rate drops below 60 per minute." "You should contact your provider if your pulse rate drops below 60 per minute." The nurse should teach the client how to monitor his pulse rate and further instruct the client to withhold the medication and notify his provider if his pulse rate drops below 60/min. A community health nurse is teaching a group of older adult clients about interventions to prevent pneumonia. Which of the following instructions should the nurse include in the teaching? "Obtain a pneumococcal vaccination every 2 years." "Contact your provider if you have a fever that lasts 18 hours." "Wash your hands when you return home from running errands." "Avoid exposure to cold air by shopping inside enclosed malls." "Wash your hands when you return home from running errands." The nurse should instruct clients that handwashing is one way to avoid organisms that can cause pneumonia. Handwashing after using the restroom or being in public areas can minimize the risk of developing pneumonia.
Limit daily intake of foods high in carbohydrates. Less than 30% of daily calories should come from fat. The nurse should instruct the client to choose foods low in fat and ensure that less than 30% of her daily total caloric intake is from fat. Limiting daily fat intake will improve lipid levels. A nurse is assessing a client whose ABG results are pH 7.51, PaCO2 29 mm Hg, and HCO3- 24 mEq/L. Which of the following findings should the nurse expect? Paresthesias Bradycardia Muscle flaccidity Respiratory depression Paresthesias One of the manifestations of respiratory alkalosis is numbness and tingling, or paresthesia, due to a decrease in calcium ionization. Other manifestations include lightheadedness, tachycardia, and cardiac dysrhythmias.
A nurse is teaching the parent of a school-age child who has pediculosis capitis about treating this parasitic infestation. Which of the following instructions should the nurse include? Wash bedding, clothes, and towels in hot water in a washing machine. Rinse the child's hair with vinegar three times a day. Seal items that are not machine washable in plastic bags for 1 week. Boil the child's combs, brushes, and hair clips for 5 min. Wash bedding, clothes, and towels in hot water in a washing machine. The nurse should instruct the parent to wash all cloth items the child has been in contact with in hot water and dry them on a hot setting in a clothes dryer for 20 min. This helps kill any lice or nits in these items. A nurse is providing teaching to an adolescent client who has methicillin-resistant Staphylococcus aureus. Which of the following instructions should the nurse provide to prevent the spread of this infection? "Expose the infected areas of skin to open air and sunlight as much as possible." "Bathe in a tub of warm water using mild soap twice daily."
