RN Concept-Based Assessment Level 1 A Test Bank 1. A nurse is admitting a client who has pulmonary tuberculosis. Which of the following transmission-based precautions should the nurse initiate? 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? 3. A nurse is teaching sleep hygiene to a client who has insomnia. Which of the following statements should the nurse make? 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? 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? 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? 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? 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? 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? 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? 11. A nurse on a medical-surgical unit is caring for a group of clients. Which of the following clients should the nurse monitor for the development of reflex urinary incontinence? 12. A nurse is documenting an assessment in a client's electronic health record when an assistive personnel (AP) asks to enter the morning blood glucose for the client. Which of the following actions should the nurse take? 13. A nurse is preparing to administer acetaminophen 120 mg PO to a toddler. Available is acetaminophen drops 80mg/0.8 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) 14. A nurse is preparing to administer 0.9% sodium chloride 1,000 mL over 8 hr IV to a client. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) 15. A nurse is providing teaching about nutrition management to the parent of an 18-month-old toddler who has phenylketonuria. Which of the following foods should the nurse recommend? 16. A nurse is preparing to extinguish a small fire in a client's room. Which of the following actions should the nurse take when using the fire extinguisher? 17. A nurse is planning meals for a client who practices Judaism and reports that she strictly adheres to orthodox dietary laws. The nurse should recognize that which of the following dietary practices applies to the client's beliefs? 18. A nurse is caring for a client who has a Clostridium difficile infection and is incontinent of stool following long-term antibiotic therapy. Which of the following actions should the nurse take? 19. A nurse is planning the menu for a client who practices Seventh-Day Adventism. Which of the following food selections should the nurse make? 20. A nurse in a long-term care facility discovers a small fire in a client's trash can. After moving the client to safety, which of the following actions should the nurse take next? 21. A community health nurse is developing a brochure about the use of smokeless tobacco. Which of the following information should the nurse plan to include? 22. A nurse is preparing to administer three medications to a client who has an NG tube: a levothyroxine tablet, an ibuprofen gel cap, and a delayed-release omeprazole capsule. Which of the following actions should the nurse take? 23. A nurse is caring for a child who has contact dermatitis due to poison ivy. The parent asks the nurse how to prevent further reactions. Which of the following responses should the nurse make? 24. A nurse is planning care for a client who has an indwelling urinary catheter. Which of the following interventions should the nurse include in the plan to prevent the development of a catheter-associated urinary tract infection (CAUTI)? 25. A nurse in a long-term care facility is admitting a new client following a brief stay in acute care. In adherence with the Joint Commission National Patient Safety Goals regarding medication administration, which of the following actions should the nurse take? 26. A nurse is creating a plan of care for a client who is non-ambulatory and has bladder and bowel incontinence. Which of the following interventions should the nurse include to prevent skin breakdown? 27. A home health nurse is providing teaching to the parent of a child who is receiving chemotherapy and experiencing nausea. Which of the following statements should the nurse make? 28. A nurse is caring for a client who has cancer and is planning discharge to go home with hospice care. Which of the following statements by the client indicates that he is experiencing spiritual distress? 29. A nurse is beginning nutrition counseling with a client who has a BMI of 34.2. Which of the following questions should the nurse ask first to address the client's excessive nutrition and obesity? 30. A nurse is administering enoxaparin subcutaneously to a client who is postoperative and is at risk of thromboembolic events. Which of the following actions should the nurse take? 31. A nurse is searching electronic databases for clinical research about behavioral indicators of pain in an infant. Which of the following online sources should the nurse select to research this infant care issue? 32. A nurse is planning to use an interpreter to assist her when interviewing a client who does not speak the same language as the nurse. Which of the following actions should the nurse plan to take? 33. A nurse is planning a community health program about substance use disorders. Which of the following information should the nurse include when discussing the guidelines for safe limits of alcohol consumption? 34. A nurse is caring for a client who is 2 days postoperative following an above-the-knee amputation. The client states he is experiencing a dull, burning pain in the leg that was amputated. Which of the following actions should the nurse take to treat the client's neuropathic pain? 35. A nurse is developing a plan of care for an older adult who is experiencing functional incontinence following hip arthroplasty. Which of the following interventions should the nurse include? 36. A nurse is preparing to administer morphine 5 mg IM form a 10 mg/mL vial to help manage a client's acute pain. Which of the following actions should the nurse plan to take after administering a controlled substance? 37. A nurse is preparing to administer a medication via intermittent IV bolus to a client who is receiving a continuous infusion via an infusion pump. The client's IV fluid solution is incompatible with the bolus. Which of the following actions should the nurse plan to take first? 38. A nurse is assessing the spiritual wellbeing and development of a preschooler. The nurse asks the preschooler, "Why is it wrong for you to kick your baby sister?" Which of the following responses should the nurse expect? 39. A nurse is planning care for a client who has bacterial meningitis caused by Haemophilus influenza. Which of the following infection control interventions should the nurse include in the plan? 40. A nurse at a provider's office is counseling a client who reports insomnia. Which of the following statements should the nurse make to include the client's preferences into a sleep promotion plan? 41. A nurse is teaching an older adult client about accessing electronic resources for health care information on the internet. Which of the following statements should the nurse include in the teaching? 42. A nurse in an emergency room is caring for an infant who requires emergency surgery. The infant is accompanied by his 16-year-old mother and his maternal grandfather. Which of the following actions should the nurse take when assisting with informed consent? 43. A nurse is preparing to administer an immunization via IM injection into an adult client's deltoid muscle. Which of the following actions should the nurse take? 44. A nurse enters a client's room and finds the client lying on the floor. The client states that on the way to the bathroom her "knee locked," causing her to fall. Which of the following actions should the nurse take first? 45. A nurse is performing a focused assessment on a client who has chronic pain due to fibromyalgia. Which of the following questions should the nurse ask to assess the quality of the client's pain? 46. A nurse is assessing a preschooler who has a urinary tract infection (UTI). Which of the following findings should the nurse expect? 47. A nurse in a long-term care facility is performing a fall risk assessment on a newly admitted client using the Timed Up and Go (TUG) test. The client reports using a tripod cane for ambulation. Which of the following actions should the nurse take when using this test? 48. A nurse is reviewing the medication administration record of a client who is 2 days postoperative following abdominal surgery. The nurse should identify that which of the following medications can result in delayed wound healing? 49. A nurse is talking with a client who reports difficulty adjusting to the death of her partner. Which of the following responses by the nurse demonstrates the therapeutic communication technique of reflecting? 50. A nurse is caring for a client who is morbidly obese and is 3 days postoperative following bariatric surgery. Which of the following dietary recommendations should the nurse make? 51. A nurse in a provider's office is caring for a male client who just turned 50 years old. The client has no significant health problems or family history of health problems. Which of the following preventive health screenings should the nurse recommend? 52. A nurse is using therapeutic communication to attempt de-escalation with a client who is yelling at staff members. Which of the following statements should the nurse make? 53. A charge nurse is observing a newly licensed nurse prepare medications for a client. Which of the following actions by the newly licensed nurse adheres to safe medication administration practices? 54. A nurse is caring for a child who has celiac disease. Which of the following items should the nurse remove from the child's meal tray? 55. A newly licensed nurse asks a charge nurse where to find information about scope of practice for registered nurses. Which of the following responses should the charge nurse make? 56. A nurse is preparing to collect a stool specimen from a client who has had diarrhea for 3 days, with fever and abdominal cramping. When reviewing the client's recent medication administration record, the nurse should recognize that treatment with which of the following medications increases the client's risk of developing a Clostridium difficile infection? 57. A nurse is providing teaching to a client who has chronic fatigue syndrome. Which of the following statements should the nurse make? 58. A nurse is preparing to contact a client's provider regarding the need for a prescription for pain medication. When using the Situation, Background, Assessment, Recommendation (SBAR) communication tool, the nurse should provide which of the following information in the assessment portion of the tool? 59. A nurse is teaching a young adult female client about health screening for breast cancer. Which of the following statements by the client indicates an understanding of breast self-examination (BSE)? 60. A nurse on a medical-surgical unit is caring for a group of clients. The nurse should identify that which of the following types of pain are classified as neuropathic? (Select all that apply.) 61. A nurse is teaching a client who is postpartum about preventing injury when using car seat for her newborn. Which of the following instruction should the nurse include? 62. A charge nurse is educating unit staff about the cultural aspects of client care following death. Which of the following statements by assistive personnel indicates an understanding of the teaching? 63. A nurse is providing change-of-shift report about a group of clients to the oncoming nurse at the end of the shift. Which of the following statements should the nurse include? 64. A nurse is teaching the parent of a toddler about home injury prevention. When discussing snacks, which of the following statements by the parent indicates an understanding of the teaching? 65. A nurse is assessing a client who has fibromyalgia. Which of the following treatment modality prescriptions should the nurse expect for the client's mixed pain? 66. A nurse is caring for an older adult client who has a leg wound following a fall on the stairs. The nurse should identify which of the following factors as an exposed, age-related change in older adults that can impair wound healing? 67. A nurse is asked by a provider to perform an invasive procedure for which he has not received training. Which of the following actions should the nurse take to ensure that it is within his legal scope of practice to perform this procedure? 68. A nurse is caring for an older adult client who has osteoarthritis and plans to go to an assisted living facility due to decreased mobility. Which of the following actions should the nurse take when acting in the role of client advocate? 69. A nurse is teaching about advance directives with an older adult client who has a terminal illness. Which of the following statements should the nurse make? 70. A nurse is preparing to administer intermittent enteral nutrition via a client's NG tube. In which order should the nurse take the following actions? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) 71. A nurse is preparing to administer enoxaparin subcutaneously to a client who is postoperative following orthopedic surgery. The nurse should plan to administer this medication in which of the following locations? 72. A nurse is administering ophthalmic solution to a client who has bacterial conjunctivitis. Which of the following actions should the nurse take? 73. A nurse is providing dietary teaching to a client who has diarrhea. Which of the following instructions should the nurse include? 74. A charge nurse is teaching a group of newly licensed nurses how to prevent errors during administration of blood transfusions. Which of the following actions should the nurse include? 75. A nurse is caring for a client who has dysphagia following a stroke. Which of the following actions should the nurse take to facilitate safe swallowing and decrease the risk of aspiration? 76. A nurse is planning car for a client who has breast cancer and is scheduled for chemotherapy. The client reports experiencing chemotherapy-induced nausea and vomiting (CINV) during her previous round of treatment. Which of the following interventions should the nurse include in the client's plan of care? 77. A nurse is teaching a client who has rheumatoid arthritis about chronic pain management. Which of the following statements by the client indicates an understanding of the teaching? 78. A nurse is planning care for a newly-admitted school-age child who has rubeola. Which of the following isolation precautions should the nurse plan to initiate? 79. A home health nurse manager is assisting in the implementation of an electronic medical record (EMR) system for client care. Which of the following actions should the nurse manager take to promote interoperability? 80. A nurse is counseling a client who has a family history of colorectal cancer about management of nutrition to help prevent gastrointestinal (GI) cancers. Which of the following images indicates a food or beverage the nurse should encourage the client to include liberally in his diet? 81. A nurse is providing discharge teaching about nutrition management to a client who has COPD. Which of the following instructions should the nurse include in the teaching? 82. A nurse is caring for a 2-year-old toddler who is immediately postoperative. Which of the following pain scales should the nurse use to assess the toddler's pain level? 83. A nurse is planning to implement bladder retraining for a client who has urge urinary incontinence. Which of the following actions should the nurse plan to take? 84. A nurse is developing a plan of care for a client who has urinary incontinence. Which of the following actions should the nurse include? 85. A nurse is preparing a client for an elective vaginal hysterectomy when the client states, "My doctor said there are more conservative ways to treat my problem. I realize now that I don't want this surgery, but I already signed that consent form." Which of the following responses should the nurse make? 86. A nurse on a pediatric unit is admitting an infant who has pertussis. Which of the following isolation precautions should the nurse initiate? 87. A nurse is assessing for acute pain in a client who is postoperative. The client has dementia and is nonverbal. Which of the following findings should the nurse identify as a need for administration of a PRN pain medication? 88. A nurse is developing a plan of care for an older adult client who is at risk of falling. Which of the following fall prevention measures should the nurse include in the plan? 89. A hospice nurse is planning care for a client who has terminal cancer. The client tells the nurse that she practices the Hindu religion. Which of the following interventions should the nurse include in the plan of care to support the client's religious beliefs? 90. A nurse is caring for a 47-year-old female client who has urinary incontinence. Which of the following actions should the nurse take first? 91. A nurse is planning care to prevent a catheter-related blood stream infection for a client who is receiving IV fluid therapy. Which of the following interventions should the nurse include in this plan? 92. A nurse is preparing to admit a client to the hospital. Which of the following actions should the nurse take first? 93. A nurse manager is developing a facility policy about the use of a fax machine to communicate information from a client's electronic medical record (EMR). Which of the following actions should the nurse include in the policy? 94. A nurse is teaching a client about strategies to prevent recurrent constipation. Which of the following instructions should the nurse include? (Select all that apply.) 95. A nurse in an orthopedic clinic is documenting data about several clients. Which of the following actions should the nurse take to comply with the regulations of the Health Insurance Portability and Accountability Act (HIPAA) 96. A community health nurse is participating in a task force initiative to reduce the incidence of disease from injection drug use among the city's homeless population. Which of the following plans should the nurse recommend as part of tertiary prevention? 97. A nurse in a community health clinic is screening a 10-year-old girl for scoliosis. Which of the following instructions should the nurse give the child for this examination? 98. A nurse is providing teaching to the parent of a 6-year-old girl about preventing urinary tract infections. Which of the following statements by the parent indicates an understanding of the teaching? 99. A nurse in a mental health facility is caring for a client who is exhibiting violent behavior and has been placed in seclusion. Which of the following actions should the nurse take? 100. A nurse is preparing to document care in a client's medical record. In adherence with the Joint Commission National Patient Safety Goals regarding communication errors, which of the following entries should the nurse make?