(LATEST 2023) RN CONCEPT-BASED ASSESSMENT LEVEL 2 (30 Q&A)

lOMoARcPSD| (LATEST 2023) RN CONCEPT-BASED ASSESSMENT LEVEL 2 (30 Q&A) 1. 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? a- "The adhesive bandages on my incision will fall off as the incision heals." b- "I will be able to take a shower in 1 week." c- "I will need to follow a liquid diet for the first 3 days after surgery." d- "I can begin to resume my normal activity level in 2 weeks. CORRECT: a- 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. INCORRECT: b- The nurse should instruct the client that she can shower or bathe the day following the surgery. c- The nurse should instruct the client to resume a regular diet following surgery and slowly introduce foods containing fat to determine tolerance. d- The nurse should instruct the client to rest for the first 24 hours following surgery and then begin resuming normal activities. The client should be able to resume usual activities within 1 week. 2. A nurse is assessing a client who has Graves' disease. Which of the following findings should the nurse expect? a- Somnolence b- Cold intolerance c- Exophthalmos d- Dry, scaly skin CORRECT: c- The nurse should expect a client who has Graves' disease, an autoimmune form of hyperthyroidism, to experience exophthalmos, which is protrusion of the eyeballs. INCORRECT: a- The nurse should expect a client who has hyperthyroidism to experience insomnia. Somnolence is a common manifestation of Hypothyroidism. b- The nurse should expect a client who has hyperthyroidism to experience heat intolerance. cold intolerance is a common manifestation of Hypothyroidism d- The nurse should expect a client who has hyperthyroidism to exhibit warm, moist, and smooth skin. Cool, dry scaly skin is a common manifestation of Hypothyroidism. 3. 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? a- "I will apply the lotion once a day for 1 week." b_ "I will rub the lotion thoroughly from my face to my toes." c- "I will wash the lotion off 12 hours after I apply it." d- " I should avoid bathing for 6 hours prior to applying the lotion." CORRECT: c- The nurse should instruct the client to apply the lotion and leave it in place fore 8 to 12 hours and then remove it by washing it off. INCORRECT: a- The nurse should instruct the client to apply the lotion, once. If live mites are still present, the nurse should instruct the client to reapply a second application one week following the first application. b- The nurse should instruct the client to apply approximately 60mL of the lotion in a thin film covering the body from the neck down. d- The nurse should instruct the client to bathe with soap and water, dry the skin well, and allow it to cool prior to applying the lotion. 4. A nurse is teaching a client who has GERD about ways to prevent reflux. Which of the following information should the nurse include in the teaching? a- Drink tomato juice with the breakfast meal. b- Suck on peppermint when having indigestion. c- Elevate the head of the bed 10 cm (4 in) using wooden blocks d- Plan to finish eating at least 3 hours before bedtime. CORRECT: d- The nurse should encourage the client not to eat anything at least 3 hours before bedtime to prevent reflux. INCORRECT: a- The nurse should tell the client not to drink tomato juice or any acidic beverages because acidic beverages can increase reflux. b- The nurse should encourage the client not to suck on peppermint because it increases reflux. c- The nurse should instruct the client to elevate the head of the bed 15.2 to 30.5 cm (6 to 12 in) by placing a foam wedge under the head of the bed to decrease reflux. 5. A nurse is teaching a client who has a deep-vein thrombosis about a new prescription for warfarin. Which of the following client statements indicates an understanding of the teaching? a- "I will stop taking the medication immediately if I experience nausea." b- "I should contact my provider if I notice a pink-tinged color to my urine." c- "I will increase my dietary intake of spinach." d- "I will not be able to use an electric razor while I am taking this medication." CORRECT: b- 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. INCORRECT: a- The nurse should instruct the client not to abruptly stop taking this medication. If the client needs to discontinue the medication, the provider will taper the dose gradually. c- The nurse should review foods that are high in vitamin K with the client and instruct the client to maintain consistent intake of these foods. Inconsistent intake of these foods, such as increasing the intake of spinach, can result in a fluctuation of prothrombin time or INR levels. d- The nurse should instruct the client to use an electric razor for shaving to reduce the risk of the risk of bleeding from a bladed razor cut. 6. A nurse is reviewing the medical record of a client who has a peptic ulcer. Which of the following findings is a priority to report to the provider? a- Melena stools b- Hemoglobin 7.6 mg/dL c- Weight gain of 1.4kg (3lb) in 2 weeks d- Dyspepsia during the day CORRECT: b - 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 is an indication of the peptic ulcer that is chronically bleeding. INCORRECT: a- Melena stools are nonurgent because they are an expected finding for a client who has a peptic ulcer that bleeds; therefore, there is another finding that is the nurse's priority. c- Weight gain is nonurgent because it is an expected finding due to the manifestation of indigestion that can occur for a client who has a peptic ulcer and the urge to eat to decrease dyspepsia; therefore, there is another finding that is the nurse's priority. d- Dyspepsia, or indigestion, is nonurgent because it is an expected finding that can occur for a client who has a peptic ulcer; therefore, there is another finding that is the nurse's priority. 7. 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? a- "I will avoid drinking grapefruit juice." b- "I will chew the medication if I can't swallow it whole." c- "I will call the doctor if I have muscle pain in my back." d- "I will take this medication on an empty stomach." CORRECT: c- 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. INCORRECT: a- Grapefruit juice can alter the effects of many medications, including lovastatin, cyclosporine, and buspirone, but it does not affect extended-release metformin. b- Extended-release metformin is designed to be metabolized over a prolonged period of time. Chewing or crushing the tablets can result in excessive absorption of the medication all at once. d- The client should take extended-release metformin once a day with his evening meal to help improve absorption due to the slower gastrointestinal transit time overnight. 8. 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? a- "Obtain a pneumococcal vaccination every 2 years." b- "Contact your provider if you have a fever that lasts 18 hours." c- "Wash your hands when you return home from running errands." d- "Avoid exposure to cold air by shopping inside enclosed malls." CORRECT: c- 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. INCORRECT: a- The nurse should recommend that clients who have chronic health conditions and those over the age of 65 obtain a pneumococcal vaccination. Some providers will administer a second vaccination after 5 years. b- The nurse should instruct clients who have a cold or influenza to notify their provider if they have a fever lasting more than 24 hours, if manifestations last longer than 7 days, or if manifestations worsen. Addressing viral or bacterial infections in the early stages can help prevent the development of pneumonia. d- The nurse should instruct clients to avoid crowded public areas, such as a shopping mall, during cold and flu season, which occurs during the winter. Being in an enclosed space with a group of people increases the risk of transmission of respiratory bacteria. 9. A nurse is assessing a client whose ABG results are pH 7.51, PaCO2 29 mmHg, and HCO3- 24 mEq/L. Which of the following findings should the nurse expect? a- Paresthesias b- Bradycardia c- Muscle flaccidity d- Respiratory depression CORRECT: a- 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. INCORRECT: b- A client experiencing respiratory alkalosis will exhibit tachycardia. c- A client experiencing respiratory alkalosis will exhibit hyperreflexia and muscle cramping and twitching. d- A client experiencing respiratory alkalosis will exhibit an increase in the rate and depth of respirations. 10. A nurse is providing discharge teaching for a client who had a lithotripsy to break up calculi in the right kidney. Which of the following should the nurse instruct the client to report to the provider? a- Bruising over the right flank area b- Blood-tinged urine c- Urine pH 6.0 d- Painful urination CORRECT: d- The nurse should instruct the client to immediately report flank or bladder pain, chills and fever, or difficulty urinating to the provider. Development of difficulty of urinating, including decreased urine output of pain with urination, can mean that the client is developing an infection or can signal recoccurrence of a stone. INCORRECT: a- The nurse should instruct the client that bruising over the affected kidney following lithotripsy is expected and does not need to be reported to the provider. b- The nurse should instruct the client that blood-tinged urine is a common occurrence for several days following lithotripsy and does not need to be reported to the provider. c- The nurse should instruct the client to test urine pH up to three times daily and report abnormal levels to the provider. A urine pH of 6.0 is within expected reference range and does not need to be reported to the provider. Urine that is highly alkalotic or acidic puts the client at high risk for reoccurrence of stone formation. 11. A nurse in an emergency department is assessing a client who is experiencing mild hypothermia. Which of the following manifestations should the nurse expect? a- Stupor b- Decreased pulse c- Slurred speech d- Dysrhythmias CORRECT: c- The nurse should expect a client who is experiencing mild hypothermia to exhibit manifextations such as slurred speech, shivering, decreased coordination, and diuresis. INCORRECT: a- The nurse should expect a client who is experiencing moderate hypothermia to exhibit stupor. Other manifestations of moderate hypothermia include weakness and decreased clotting. b- The nurse should expect a client who is experiencing severe hypothermia to have bradycardia. Other manifestations of severe hypothermia include severe hypotension, bradypnea, and acid- base imbalance. d- The nurse should expect a client who is experiencing severe hypothermia severe hypothermia to have dysrhythmias, such as ventricular fibrillation or asystole. Other manifestations of severe hypothermia include severe hypotension, bradypnea, and acid-base imbalance. 12. A nurse has arrived at the site of an accident where a client has sustained a traumatic amputation of the big toe. Identify the sequence of steps the nurse should take to treat the musculoskeletal trauma. 1- Apply direct pressure with layers of dry cloth. 2- Call 911 and examine the amputation site. 3- Place the toe in a bag and place the bag in 1 part ice and 3 parts water. 4- Find the toe and wrap it in sterile gauze or a clean cloth. 5- Elevate the extremity above the client's heart. CORRECT: 2, 1, 5, 4, 3 13. A nurse is assessing a client who has been taking antacids frequently for GI distress. The assessment findings include drowsiness, muscle weakness, bradycardia, and hypotension. Which of the following electrolyte imbalances should the nurse suspect? a- Hypophosphatemia b- Hypochloremia c- Hypermagnesemia d- Hypernatremia CORRECT: c- The nurse should identify that frequent ingestion of antacids and laxatives that contain magnesium can cause hypermagnesemia. Manifestations include hypotension, bradycardia, absent deep tendon reflexes, weak skeletal muscle contractions, ECG changes, lethargy, and drowsiness that can progress to coma. INCORRECT: a- The nurse should identify that hypophosphatemia can cause muscle weakness, as well as seizures, nystagmus, confusion, chest and bone pain, and paresthesias. b- The nurse should identify that hypochloremia can cause dysrhythmias, as well as irritability, agitation, hyperactive deep tendon reflexes, bradypnea, and seizures. d- The nurse should identify that hypernatremia can cause lethargy, as well as fever, thirst, restlessness, hyperreflexia, nausea, vomiting, tachycardia, and hypertension. 14. A nurse is providing teaching to the parent of an infant who has gastroesophageal reflux about home care. Which of the following statements by the parent indicates an understanding of the teaching? a- "I will feed my infant a larger amount of formula less frequently." b- "I should feed my infant a bottle of formula within 1 hr of bedtime." c- "I should place my infant on his side to sleep." d- " I should add 1 teaspoon of rice cereal to my infant's formula." CORRECT: d- The parent should add 1 teaspoon of rice cereal in order to thicken the formula. this will decrease the incidence of gastric reflux. INCORRECT: a- The parent should feed the infant smaller amounts of formula more frequently throughout the day. Smaller feedings decrease the likelihood of reflux occurring. b- The parent should avoid feeding the infant a bottle close to bedtime. Feeding prior to sleep increases the incidence of reflux of gastric contents. c- The parent should place the infant on his back to sleep. The parent can lay the infant in the prone position for a few minutes a day while continuously observing the infant for safety. 15. A nurse in an emergency department is assessing a preschooler who has severe dehydration as a result of gastroenteritis and is receiving isotonic IV fluids. Which of the following findings should the nurse identify as an indication that the treatment is effective? a- Urine output 0.5 mL/kg/hr b- Capillary refill 3 seconds c- Heart rate 148/min d- Brisk skin turgor CORRECT: d- The nurse should expect the child to have brisk skin turgor if fluid replacement therapy is effective. INCORRECT: a- The nurse should expect the child to have a urine output greater than 1 mL/kg/hr if fluid replacement therapy has been effective. b- The nurse should expect the child to have a capillary refill of 2 secs or less if fluid replacement therapy has been effective. c- Tachycardia is a manifestation of dehydration. The nurse should expect the child to have a heart rate within the expected reference range for a 3- to 4-year-old child if fluid replacement therapy is effective. 16. A nurse is reviewing the laboratory report of a client who is taking exenatide to treat type 2 diabetes mellitus. The nurse should recognize that which of the following laboratory results is an indication of an adverse reaction to the medication? a- HbA1c 6.8% b- Hct 45% c- Creatinine 0.9% mg/dL d- Lipase 185 units/L CORRECT: d- The nurse should recognize that an elevated lipase is an indication of pancreatitis, which can indicate the client is experiencing an adverse effect to exenatide. Physical manifestations of pancreatitis include ongoing, severe abdominal pain and vomiting. INCORRECT: a- The nurse should recognize that a hemoglobin A1c value of 6.8% is an indication that the client's diabetes is well controlled, which is a therapeutic response to the exenatide. b- The nurse should recognize that a hematocrit of 45% is within the expected reference range of 42% to 52% for men and 37% to 47% for women. c- The nurse should recognize that a creatinine of 0.9 mg/dL is within the expected reference range. The nurse should monitor the client's BUN and creatinine levels because renal failure is an adverse effect of exenatide. 17. A nurse is teaching a client who has atherosclerosis about self-care. Which of the following instructions should the nurse include in the teaching? a- Consume five to seven servings of red meat per week b- Limit daily calorie intake from saturated fat to 18% c- Increase fiber intake to at least 30g per day d- Exercise 2 days a week for at least 60 min. CORRECT: c- The nurse should instruct the client to increase daily fiber intake to at least 30g. Fiber assists in the elimination of lipids and minimizes the development of atherosclerosis. INCORRECT: a- The nurse should instruct the client to decrease the intake of red meat. Red meat is high in cholesterol and saturated fat, which can worsen atherosclerosis. b- The nurse should instruct the client to limit calories from saturated fat to no more than 6% of daily intake. The nurse should instruct the client to consume low-fat and nonfat foods. d- The nurse should instruct the client to exercise 3 to 4 days a week for at least 40 min. The client should engage in moderate to strenuous physical exercise. 18. A nurse in a provider's office is assessing a preschooler who has developed contact dermatitis following exposure to poison ivy. Which of the following statements should the nurse make to the child's parent regarding disease management? a- "Wash your child's exposed clothing in cold water using powder detergent." b- "Keep your child away from other children for 10 days after lesions appear." c- "Scrub you child's affected areas with an antibacterial soap every other day." d- "Place your child in an oatmeal bath using tepid water for 15 minutes." CORRECT: d- The nurse should instruct the parent that tepid baths containing oatmeal or mineral oil can decrease itching and evenly disperse the antipruritic solution. The parent should not place the child in a hot bath as this can aggravate the child's condition and increase itching. INCORRECT: a- The nurse should instruct the parent to carefully remove the child's exposed clothing and wash it in hot, rather than cold, water. This will remove the oil, which causes the skin reaction. b- Keeping the child away from other children for 10 days after the lesions appear is not necessary. Contact dermatitis from poison ivy is not contagious or spread through contact with the infected child. Contact dermatitis occurs following exposure to the oil in the poison ivy plant. c- The nurse should instruct the parent not to scrub the child's affected areas with an antibacterial or harsh soap. This can remove protective skin oils and allow the dermatitis to spread. The child should shower with soap and water. 19. A nurse is assessing a 3-month-old infant who has gastroenteritis with severe dehydration. Which of the following findings should the nurse expect? a- Flat anterior fontanel b- Capillary refill 2 seconds c- 5% weight loss d- Absence of tears CORRECT: d- The nurse should expect an infant who has severe dehydration to have an absence of tears when crying. Other manifestations include tachycardia, hypotension, intense thirst, and oliguria or anuria. INCORRECT: a- The nurse should expect an infant who has mild dehydration to have a flat anterior fontanel. Manifestations of severe dehydration include, sunken anterior fontanel, parched mucus membranes, sunken eyeballs, and tachycardia. b- The nurse should expect to an infant who has moderate dehydration to have a capillary refill of 2 to 4 seconds. Manifestations of severe dehydration include capillary refill time of greater than 4 seconds, parched mucus membranes, sunken eyeballs, and tachycardia. c- The nurse should expect an infant who has mild dehydration to have a weight loss of 3 to 5%. Manifestations of severe dehydration include weight loss of greater than 10% , parched mucus membranes, sunken eyeballs, and tachycardia. 20. A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? (Select all that apply." a- Nocturia b- Dependent edema c- Dyspnea d- Hacking cough e- Anorexia Correct: a, c, d - Left-sided heart failure causes oliguria during the day and nocturia during sleeping hours, pulmonary manifestations, such as dyspnea, orthopnea, crackles, and wheezes, and a hacking cough that worsens at night and eventually produces frothy sputum.