RN CONCEPT-BASED ASSESSMENT LEVEL 2 EXAM QUESTIONS
AND CORRECT ANSWERS WITH RATIONALES
A nurse is caring for a client who has pneumonia. Which of the following actions is
the priority for the nurse to take?
-Monitor intake and output
-Provide teaching about antibiotic therapy
-Administer the influenza vaccine
-Observe the client perform incentive spirometry - ANSWER: Observe the client
perform incentive spirometry
When using the airway, breathing, and circulation framework, the priority action the
nurse should take is to observe the client perform incentive spirometry. Incentive
spirometry improves gas exchange and oxygenation and stimulates coughing, which
assists in clearing secretions.
A nurse is assessing a client who has hyperthyroidism and has been taking
methimazole for 6 months. Which of the following findings indicates a therapeutic
response to the medication
-The client's skin is warm and moist
-The client reports sleeping longer during the night
-The client is experiencing increased bowel movements
-The client's weight is 1.4 kg (3.1 lb) less than baseline - ANSWER: The client reports
sleeping longer during the night
The nurse should recognize that insomnia is a manifestation of hyperthyroidism. The
client's ability to sleep longer during the night indicates a therapeutic response to
the medication.
A nurse is planning discharge teaching for the guardian of a child who had a cardiac
catheterization. Which of the following instructions should the nurse include?
-Monitor the site daily for drainage
-Leave the pressure dressing on the 48 hr
-Administer aspirin if the child reports pain
-Resume tub baths in 24hr - ANSWER: Monitor the site daily for drainage
The nurse should instruct the guardian to monitor the site daily for manifestations of
infection, such as drainage, redness, and swelling. The guardian should report these
findings to the provider.
A nurse is reviewing the medical record of a client who is receiving total parenteral
nutrition for a malabsorption disorder. Which of the following findings should the
nurse identify as an indication that the client's nutritional status is improving?
-Intake of fluid is less than output of urine over the past 2 days
-1kg (2.2 lb) weight gain over the past 2 days
,-Blood glucose 206 mg/dL
-Prealbumin 13 mg/dL - ANSWER: 1 kg (2.2 lb) weight gain over the past 2 days
Total parenteral nutrition is administered to clients who have inflammatory bowel
disorders and are unable to tolerate enteral nutrition. A weight gain of 0.5 kg (1.1 lb)
daily is an indication that the client is responding to the parenteral nutrition.
A nurse is performing a focused assessment on a client who has cholelithiasis and
reports pain. Which of the following areas should the nurse assess? - ANSWER: Right
upper quadrant
The nurse should assess the gallbladder for the presence of pain or discomfort as a
result of biliary colic, which is caused by a gallbladder stone obstructing the bile duct.
The pain can radiate from the right upper quadrant of the client's abdomen to the
client's right shoulder.
The nurse is providing discharge teaching to a client about managing diverticulitis.
Which of the following statements should the nurse include in the teaching?
-"Use bisacodyl suppositories to stimulate a bowel movement"
-"Avoid lifting objects greater than 50 pounds"
-"Consume a clear liquid diet until symptoms resolve"
-"Take a probiotic 15 minutes after taking a prescribed antibiotic to prevent
antibiotic-related diarrhea" - ANSWER: "Consume a clear liquid diet until symptoms
resolve"
The nurse should recommend the client consume a clear liquid diet until
manifestations such as abdominal pain, nausea, and vomiting have resolved. A clear
liquid diet is low in fiber and does not stimulate intestinal motility.
A nurse is providing teaching to a client who has a methicillin-resistant
Staphylococcus aureus (MRSA) skin infection. Which of the following client
statements indicates an understanding of the management of antibiotic resistant
infections?
-I will keep the infected area open to air to help it heal
-I can sleep in the same bed as my partner after I have been taking antibiotics for 24
hours
-I should sit on upholstered chairs instead of hardback chairs
-I will wash all uninfected skin areas with a fresh washcloth - ANSWER: I will wash all
uninfected skin areas with a fresh washcloth
The nurse should instruct the client to wash the uninfected skin areas with a fresh
washcloth to prevent contamination of the unaffected areas of the skin with the
MRSA infection.
A nurse is providing teaching to a client about preventing hearing loss from trauma.
Which of the following instructions should the nurse include in the teaching?
-Keep your mouth open when sneezing
, -Block one nostril when blowing your nose
-Use an ear wick candle to remove excess cerumen from the canal
-Lubricate cotton-tipped applicators with mineral oil to clean the ear canal -
ANSWER: Keep your mouth open when sneezing
The nurse should instruct the client to keep the mouth open while sneezing to
reduce the pressure in the middle ear. Sudden pressure changes can damage the
ossicles and perforate the ear drum.
A nurse is teaching a client who recently lost his partner to a terminal illness. The
client asks how his 4-year-old son is expected to react to the death of his partner.
Which of the following information should the nurse include in the teaching?
-A preschooler has no concept of death
-A preschooler is often interested in what happens to the body after death
-A preschooler often believes that death is reversible
-A preschooler understands that death happens to everyone - ANSWER: A
preschooler often believes that death is reversible
The nurse should identify that preschoolers tend to have difficulty understanding the
reality of death and often believe that it is reversible. Because of magical thinking,
the preschooler might think that his thoughts or behavior might have caused the
person to die.
A nurse is assessing a client who has gestational diabetes and ketoacidosis. Which of
the following manifestations should the nurse expect?
-Increased urination
-Sweating
-Dizziness
-Loose stools - ANSWER: Increased urination
The nurse should expect the client to exhibit manifestations of hyperglycemia,
including increased thirst, nausea, vomiting, increased urination, flushed dry skin,
acetone breath odor, and a weak, rapid pulse.
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?
-Serous drainage is present on the pin site dressings
-Flushing of the skin on the right arm
-Bounding pulse palpated in the radial artery
-Numbness to the fingers on the right arm - ANSWER: Numbness to the fingers on
the right arm
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
AND CORRECT ANSWERS WITH RATIONALES
A nurse is caring for a client who has pneumonia. Which of the following actions is
the priority for the nurse to take?
-Monitor intake and output
-Provide teaching about antibiotic therapy
-Administer the influenza vaccine
-Observe the client perform incentive spirometry - ANSWER: Observe the client
perform incentive spirometry
When using the airway, breathing, and circulation framework, the priority action the
nurse should take is to observe the client perform incentive spirometry. Incentive
spirometry improves gas exchange and oxygenation and stimulates coughing, which
assists in clearing secretions.
A nurse is assessing a client who has hyperthyroidism and has been taking
methimazole for 6 months. Which of the following findings indicates a therapeutic
response to the medication
-The client's skin is warm and moist
-The client reports sleeping longer during the night
-The client is experiencing increased bowel movements
-The client's weight is 1.4 kg (3.1 lb) less than baseline - ANSWER: The client reports
sleeping longer during the night
The nurse should recognize that insomnia is a manifestation of hyperthyroidism. The
client's ability to sleep longer during the night indicates a therapeutic response to
the medication.
A nurse is planning discharge teaching for the guardian of a child who had a cardiac
catheterization. Which of the following instructions should the nurse include?
-Monitor the site daily for drainage
-Leave the pressure dressing on the 48 hr
-Administer aspirin if the child reports pain
-Resume tub baths in 24hr - ANSWER: Monitor the site daily for drainage
The nurse should instruct the guardian to monitor the site daily for manifestations of
infection, such as drainage, redness, and swelling. The guardian should report these
findings to the provider.
A nurse is reviewing the medical record of a client who is receiving total parenteral
nutrition for a malabsorption disorder. Which of the following findings should the
nurse identify as an indication that the client's nutritional status is improving?
-Intake of fluid is less than output of urine over the past 2 days
-1kg (2.2 lb) weight gain over the past 2 days
,-Blood glucose 206 mg/dL
-Prealbumin 13 mg/dL - ANSWER: 1 kg (2.2 lb) weight gain over the past 2 days
Total parenteral nutrition is administered to clients who have inflammatory bowel
disorders and are unable to tolerate enteral nutrition. A weight gain of 0.5 kg (1.1 lb)
daily is an indication that the client is responding to the parenteral nutrition.
A nurse is performing a focused assessment on a client who has cholelithiasis and
reports pain. Which of the following areas should the nurse assess? - ANSWER: Right
upper quadrant
The nurse should assess the gallbladder for the presence of pain or discomfort as a
result of biliary colic, which is caused by a gallbladder stone obstructing the bile duct.
The pain can radiate from the right upper quadrant of the client's abdomen to the
client's right shoulder.
The nurse is providing discharge teaching to a client about managing diverticulitis.
Which of the following statements should the nurse include in the teaching?
-"Use bisacodyl suppositories to stimulate a bowel movement"
-"Avoid lifting objects greater than 50 pounds"
-"Consume a clear liquid diet until symptoms resolve"
-"Take a probiotic 15 minutes after taking a prescribed antibiotic to prevent
antibiotic-related diarrhea" - ANSWER: "Consume a clear liquid diet until symptoms
resolve"
The nurse should recommend the client consume a clear liquid diet until
manifestations such as abdominal pain, nausea, and vomiting have resolved. A clear
liquid diet is low in fiber and does not stimulate intestinal motility.
A nurse is providing teaching to a client who has a methicillin-resistant
Staphylococcus aureus (MRSA) skin infection. Which of the following client
statements indicates an understanding of the management of antibiotic resistant
infections?
-I will keep the infected area open to air to help it heal
-I can sleep in the same bed as my partner after I have been taking antibiotics for 24
hours
-I should sit on upholstered chairs instead of hardback chairs
-I will wash all uninfected skin areas with a fresh washcloth - ANSWER: I will wash all
uninfected skin areas with a fresh washcloth
The nurse should instruct the client to wash the uninfected skin areas with a fresh
washcloth to prevent contamination of the unaffected areas of the skin with the
MRSA infection.
A nurse is providing teaching to a client about preventing hearing loss from trauma.
Which of the following instructions should the nurse include in the teaching?
-Keep your mouth open when sneezing
, -Block one nostril when blowing your nose
-Use an ear wick candle to remove excess cerumen from the canal
-Lubricate cotton-tipped applicators with mineral oil to clean the ear canal -
ANSWER: Keep your mouth open when sneezing
The nurse should instruct the client to keep the mouth open while sneezing to
reduce the pressure in the middle ear. Sudden pressure changes can damage the
ossicles and perforate the ear drum.
A nurse is teaching a client who recently lost his partner to a terminal illness. The
client asks how his 4-year-old son is expected to react to the death of his partner.
Which of the following information should the nurse include in the teaching?
-A preschooler has no concept of death
-A preschooler is often interested in what happens to the body after death
-A preschooler often believes that death is reversible
-A preschooler understands that death happens to everyone - ANSWER: A
preschooler often believes that death is reversible
The nurse should identify that preschoolers tend to have difficulty understanding the
reality of death and often believe that it is reversible. Because of magical thinking,
the preschooler might think that his thoughts or behavior might have caused the
person to die.
A nurse is assessing a client who has gestational diabetes and ketoacidosis. Which of
the following manifestations should the nurse expect?
-Increased urination
-Sweating
-Dizziness
-Loose stools - ANSWER: Increased urination
The nurse should expect the client to exhibit manifestations of hyperglycemia,
including increased thirst, nausea, vomiting, increased urination, flushed dry skin,
acetone breath odor, and a weak, rapid pulse.
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?
-Serous drainage is present on the pin site dressings
-Flushing of the skin on the right arm
-Bounding pulse palpated in the radial artery
-Numbness to the fingers on the right arm - ANSWER: Numbness to the fingers on
the right arm
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
