RNSG 1430 RN Concept-Based Assessment Level 1 Online
Practice A 2020 – San Antonio College
100 Q&A
100 % CORRECCT
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 following
information 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
years old 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
, 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 bedtime
to 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 the
face
Rationale: The nurse should untie the bottom strings and then the top
strings. Finally, while still holding the strings, the nurse should remove the
mask from her face. This action prevents the nurse from touching the front
of 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 at
the 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
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
,6. A community health nurse is planning prevention strategies for hypertension
among members of her community. The nurse should identify that which of
the following 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 ethnicity
are at greatest risk of developing hypertension.
7. A community health nurse is planning interventions to promote Healthy
People 2020 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 Healthy
People 2020 initiative. Using the nursing process, the first action the
nurse should take is to assess the needs of the community. By identifying
disparities in community health, the nurse can develop interventions
targeted at the community's specific needs.
8. A nurse is reviewing a client's new prescriptions that were just documented in
the client's medical record by the provider. Which of the following abbreviations
should the nurse clarify with the provider?
Enoxaparin 40 mg SQ QD
, Rationale: The nurse should clarify this prescription with the provider.
The abbreviations "SQ" and "QD" are considered error-prone and should
not be used in documentation. The nurse should clarify that the provider
intends the prescription to be administered subcutaneously once daily.
"Subcutaneous" or "subcut" should be used instead of "SQ" and "daily"
should be used instead of "QD."
9. A nurse is talking with a client who has major depressive disorder. The client
states, "Nobody cares if I'm around or not." Which of the following responses
should the nurse take?
It sounds as though you’re feeling hopeless
Rationale: This statement by the nurse is an example of restating, which is
a therapeutic response. This technique restates the main idea the client
has expressed and allows the client to clarify any misunderstanding.
10. A nurse is preparing to administer a unit of packed RBCs to a client. In
adherence with the Joint Commission National Patient Safety Goals regarding
blood administration, which of the following actions should the nurse plan to
take?
Verify the client and blood component using a two-person process
Rationale: The Joint Commission National Patient Safety Goals regarding
blood transfusions includes improving the accuracy of client identification.
The nurse should eliminate transfusion errors related to client
misidentification by using a two-person verification process to identify the
client and the blood component.
Practice A 2020 – San Antonio College
100 Q&A
100 % CORRECCT
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 following
information 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
years old 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
, 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 bedtime
to 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 the
face
Rationale: The nurse should untie the bottom strings and then the top
strings. Finally, while still holding the strings, the nurse should remove the
mask from her face. This action prevents the nurse from touching the front
of 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 at
the 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
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
,6. A community health nurse is planning prevention strategies for hypertension
among members of her community. The nurse should identify that which of
the following 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 ethnicity
are at greatest risk of developing hypertension.
7. A community health nurse is planning interventions to promote Healthy
People 2020 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 Healthy
People 2020 initiative. Using the nursing process, the first action the
nurse should take is to assess the needs of the community. By identifying
disparities in community health, the nurse can develop interventions
targeted at the community's specific needs.
8. A nurse is reviewing a client's new prescriptions that were just documented in
the client's medical record by the provider. Which of the following abbreviations
should the nurse clarify with the provider?
Enoxaparin 40 mg SQ QD
, Rationale: The nurse should clarify this prescription with the provider.
The abbreviations "SQ" and "QD" are considered error-prone and should
not be used in documentation. The nurse should clarify that the provider
intends the prescription to be administered subcutaneously once daily.
"Subcutaneous" or "subcut" should be used instead of "SQ" and "daily"
should be used instead of "QD."
9. A nurse is talking with a client who has major depressive disorder. The client
states, "Nobody cares if I'm around or not." Which of the following responses
should the nurse take?
It sounds as though you’re feeling hopeless
Rationale: This statement by the nurse is an example of restating, which is
a therapeutic response. This technique restates the main idea the client
has expressed and allows the client to clarify any misunderstanding.
10. A nurse is preparing to administer a unit of packed RBCs to a client. In
adherence with the Joint Commission National Patient Safety Goals regarding
blood administration, which of the following actions should the nurse plan to
take?
Verify the client and blood component using a two-person process
Rationale: The Joint Commission National Patient Safety Goals regarding
blood transfusions includes improving the accuracy of client identification.
The nurse should eliminate transfusion errors related to client
misidentification by using a two-person verification process to identify the
client and the blood component.
