RNSG 1430| RN Concept-Based Assessment Level 1
1. A nurse is admitting a client who has pulmonary tuberculosis. Which of the
following transmission-based precautions should the nurse initiate?
• Airborne
• Rationale: Pulmonary tuberculosis is an infection that is transmitted by
airborne droplets smaller than 5 microns in diameter. Therefore, this client
requires airborne precautions to prevent communicating this infection to
others
2. A nurse in a mental health facility is preparing an educational program for a group of
staff nurses about the proper use of restraints. Which of the followinginformation
should the nurse plan to include?
• An adult client may be in a mechanical restraint for up to 4 hours
• Rational: The nurse should specify that a client who is 18 years or older may be
in a restraint for no more than 4 hr. Children who are 9 to 17 yearsold are
limited to 2 hr and children who are younger than 9 years old are limited to 1 hr
3. A nurse is teaching sleep hygiene to a client who has insomnia. Which of the
following statements should the nurse make?
• Exercise in the morning after arising
Page 1 of 70
, RNSG 1430| RN Concept-Based Assessment Level 1
• Rationale: Daily exercise has many benefits, including enhancing
cardiovascular, psychological, and musculoskeletal health. The nurse should
recommend that the client avoid exercising within 2 hr of bedtimeto limit
stimulation and enhance sleep
4. A nurse is preparing to leave the room of a client who is on isolation precautions.
Which of the following actions should the nurse take when removing a tied
surgical mask?
• Remove the mask by securely holding the ties and moving it away from theface
• Rationale: The nurse should untie the bottom strings and then the top strings.
Finally, while still holding the strings, the nurse should remove themask from her
face. This action prevents the nurse from touching the frontof the mask, which is
contaminated
5. A nurse is caring for an adolescent client who is in critical condition following a motor
vehicle crash in which he was the passenger. The client's parent shouts atthe nurse,
asking why her son is dying instead of the driver. Which of the following actions
should the nurse take to provide emotional support to the parent?
• Inform the parent that anger is a natural response when dealing with loss
Page 2 of 70
, RNSG 1430| RN Concept-Based Assessment Level 1
• Rationale: The nurse should identify that the parent is in the anger stage of
grief. The nurse should assist the parent to understand that anger is a natural
response to loss and encourage her to talk about her feelings
Page 3 of 70
, RNSG 1430| RN Concept-Based Assessment Level 1
6. A community health nurse is planning prevention strategies for hypertension among
members of her community. The nurse should identify that which of thefollowing
ethnic groups in the community is at greatest risk of developing hypertension?
• African Americans
• Rationale: Evidence-based practice indicates that individuals of African-
American ethnicity have the highest prevalence of hypertension. Therefore, the
nurse should identify community members of this ethnicityare at greatest risk of
developing hypertension.
7. A community health nurse is planning interventions to promote Healthy People2020
initiatives in the community. Which of the following actions should the nurse plan to
take first?
• Determine the level of health equity among groups in the community
• Rationale: Health equity among all groups in the community is a HealthyPeople
2020 initiative. Using the nursing process, the first action the nurse should take
is to assess the needs of the community. By identifyingdisparities in
community health, the nurse can develop interventions targeted at the
community's specific needs.
Page 4 of 70
1. A nurse is admitting a client who has pulmonary tuberculosis. Which of the
following transmission-based precautions should the nurse initiate?
• Airborne
• Rationale: Pulmonary tuberculosis is an infection that is transmitted by
airborne droplets smaller than 5 microns in diameter. Therefore, this client
requires airborne precautions to prevent communicating this infection to
others
2. A nurse in a mental health facility is preparing an educational program for a group of
staff nurses about the proper use of restraints. Which of the followinginformation
should the nurse plan to include?
• An adult client may be in a mechanical restraint for up to 4 hours
• Rational: The nurse should specify that a client who is 18 years or older may be
in a restraint for no more than 4 hr. Children who are 9 to 17 yearsold are
limited to 2 hr and children who are younger than 9 years old are limited to 1 hr
3. A nurse is teaching sleep hygiene to a client who has insomnia. Which of the
following statements should the nurse make?
• Exercise in the morning after arising
Page 1 of 70
, RNSG 1430| RN Concept-Based Assessment Level 1
• Rationale: Daily exercise has many benefits, including enhancing
cardiovascular, psychological, and musculoskeletal health. The nurse should
recommend that the client avoid exercising within 2 hr of bedtimeto limit
stimulation and enhance sleep
4. A nurse is preparing to leave the room of a client who is on isolation precautions.
Which of the following actions should the nurse take when removing a tied
surgical mask?
• Remove the mask by securely holding the ties and moving it away from theface
• Rationale: The nurse should untie the bottom strings and then the top strings.
Finally, while still holding the strings, the nurse should remove themask from her
face. This action prevents the nurse from touching the frontof the mask, which is
contaminated
5. A nurse is caring for an adolescent client who is in critical condition following a motor
vehicle crash in which he was the passenger. The client's parent shouts atthe nurse,
asking why her son is dying instead of the driver. Which of the following actions
should the nurse take to provide emotional support to the parent?
• Inform the parent that anger is a natural response when dealing with loss
Page 2 of 70
, RNSG 1430| RN Concept-Based Assessment Level 1
• Rationale: The nurse should identify that the parent is in the anger stage of
grief. The nurse should assist the parent to understand that anger is a natural
response to loss and encourage her to talk about her feelings
Page 3 of 70
, RNSG 1430| RN Concept-Based Assessment Level 1
6. A community health nurse is planning prevention strategies for hypertension among
members of her community. The nurse should identify that which of thefollowing
ethnic groups in the community is at greatest risk of developing hypertension?
• African Americans
• Rationale: Evidence-based practice indicates that individuals of African-
American ethnicity have the highest prevalence of hypertension. Therefore, the
nurse should identify community members of this ethnicityare at greatest risk of
developing hypertension.
7. A community health nurse is planning interventions to promote Healthy People2020
initiatives in the community. Which of the following actions should the nurse plan to
take first?
• Determine the level of health equity among groups in the community
• Rationale: Health equity among all groups in the community is a HealthyPeople
2020 initiative. Using the nursing process, the first action the nurse should take
is to assess the needs of the community. By identifyingdisparities in
community health, the nurse can develop interventions targeted at the
community's specific needs.
Page 4 of 70
