CMS quiz
A charge nurse is teaching a newly hired nurse about the facility's computerized documentation system. Which of the following actions should the nurse take?
Instruct the newly hired nurse to use direct quotes when recording client statements
If a pt has a fever what action should the nurse take?
Keep the pt bed linens dry
A nurse is caring for a pt with dehydration who has developed hypovolemic shock. Which of the following values should the nurse expect for this pt?
Hct 55%
a nurse is caring for a pt with dehydration who has developed hypovolemic shock. which of the following lab values should the nurse expect?
Hct 55%
A nurse in a providers office is reviewing the laboratory reports for a client who is at risk for heart disease. Which of the following results should the nurse report to the provider?
LDL 170 mg/dL
Supine position
Laying on back
A nurse is completing dietary teaching with a client who has heart failure and has a prescription for a 2g sodium diet. Which of the following statement made by the client indicates an understanding of the teaching?
"I can have nonfat yogurt as a dessert"
Sodium range
136-145
A nurse is planning care for four clients. Which of the following clients should the nurse see first?
A client who has pneumonia and expiratory wheezing
A nurse is performing a pre operative assessment on four clients. The nurse should identify that which of the following clients is at risk for a latex allergy?
A client who has spina bifida
Kinesthesia
Ability to sense the position and movement of body parts without visualizing them
Gustation
Ability to taste
When assisting a pt who has Dysphagia at mealtimes what action should the nurse take?
Advise pt to tuck chin downward
What precautions are used for measles?
Airborne
Which of the following muscle group is responsible for movement at the knee joint?
Antagonistic
A nurse in an urgent care is caring for a 15 year old whose symptoms suggest an STI. The parents are unavailable but the grandma accompanied the client to the clinic. Which of the following actions should the nurse take?
Ask the adolescent to sign the consent form
When using a 4 point crutch gait what instructions should the nurse include
Bear weight on both of your legs
What should be used to clean blood spills?
Chlorine bleach
A nurse is preforming guaiac testing for a client to screen for colon cancer. The nurse should identify that ingestion of which of the following foods can cause a false negative result?
Citrus fruits
A nurse is preparing to insert an NG tube for a pt. Which of the following actions will help facilitate the insertion of the tube?
Coat the tip of the tube with water soluble lubricant, ask client to swallow water while the tube enters her throat, tell the pt to tilt her head backward as insertion begins
A nurse is teaching a client how to perform active range of motion exercises of the lower extremities to improve mobility. Which of the following instructions should the nurse include in the teaching?
Complete each session two times per day
Before administering a feeding via a gastrostomy tube what should the nurse do?
Elevate the head of the pt bed
A nurse is planning an inservice training session about nutrition. Which of the following statements should the nurse include in the teaching?
Fats provide energy
A nurse is reviewing the medical record for a client who is receiving continuous enteral feedings. Which of the following findings should the nurse report to the provider?
Gastric aspirate pH of 7
A pt surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider?
Halo of erythema on the surrounding skin
A nurse is caring for a pt who is postoperative and asks for a drink. Her postoperative diet states "clear liquids" which of the following responses should the nurse make?
I am going to listen to your abdomen
Which statement should the nurse identify as an indication that the pt understands the instructions for patient controlled analgesia
I can still use my TENS unit while pushing the PCA button
What statement is an indication that a middle aged pt has completed Ericsson's developmental task for her age?
I think i have done a good job with my children since they are all independent now
When performing a breast exam what technique should the nurse use first?
Inspect both breasts simultaneously
How does a TENS unit relieve pain?
It modulates the transmission of the pain impulse
Diuresis
Large amounts of urine
Should used needles be broken after use?
No never to reduce the risk of injury`
A resident begins to choke and is coughing strongly. Which of the following actions should the nurse take?
Observe the client closely
A nurse is preparing the room for a client who is transferring from the emergency department and is on seizure precautions. Which of the following items should the nurse place in the clients room?
Oral-nasal suction
When administering an enema what action should the nurse take?
Place pt in left sims position
When collecting a stool specimen what action should the nurse take?
Place the stool specimen collection in a biohazard bag
A home health nurse enters a pt home and finds a used insulin syringe without a cap on the table. Which of the following actions should the nurse take?
Place the syringe in a puncture proof disposal container
A nurse is preparing to perform a sterile procedure for a client. Which of the following actions should the nurse include in the plan?
Position a bedside table so the sterile field can be seen continuously throughout the procedure
A charge nurse is delegating tasks for four clients. Which of the following tasks should the nurse delegate to the AP?
Prepare the room for a client who requires seizure precautions.
The specific gravity of a pt urine is 1.035 when receiving feedings through an NG tube. What action should the nurse take?
Provide more water with feedings
When performing mouth care for an unresponsive pt what action should the nurse take?
Raise the level of the bed
A nurse is caring for a pt who is receiving continuous enteral feedings via NG tube and develops diarrhea. Which of the following actions should the nurse take?
Request a prescription for an isotonic enteral nutrition formula
What should be done with empty blood bags?
Return to the blood bank in case a transfusion reaction occurs and to reduce risk of transmission of microorganisms
Which of the following methods should the nurse use to verify correct NG tube placement?
Verify initial X-ray, measure length of exposed tube, determine the pH of aspirated fluid
A nurse is planning to perform postmortem care for a client. Which of the following actions should the nurse plan to take?
Verify whether the client requires an autopsy
A nurse is caring for a client who has C diff infection. Which of the following actions should the nurse take?
Wear a cover gown when caring for the client
A nurse is performing a straight cath for a pt. Which of the following indicates the nurse is maintaining sterile technique?
Wiping the labia minora in an anateroposterior direction
How do you perform addiction of the wrist?
With palm facing downward move your wrist sideways toward your thumb
a nurse is assessing a pt who has a total calcium level of 12.7 mg/dL. which of the following findings should the nurse expect?
depressed deep tendon reflexes
A nurse is caring for a pt who has a terminal illness. The family wants to care for the pt at home. Which of the following statements indicates that the nurse understands family-centered care?
Let's set up a meeting time with the doctor to discuss your options for home care
A nurse is preparing to insert an indwelling urinary cath for a male pt. Which of the following locations should the nurse secure the urinary cath tubing?
Lower abdomen
Who would be eligible for hospice services?
A pt who has end-stage cirrhosis (anyone who has less than 6 months to live
a nurse is preparing to change the bed linens of a client who has AIDS and is incontinent of stool. which of the following PPE items should the nurse don prior to providing pt care?
gown and gloves
Gastric secretions should have a pH range of:
0-4
Which of the following is within expected range for blood pressure?
116/70
Which of the following pH values should the nurse expect when assessing a pt gastric fluid?
2
Which of the following results should the nurse identify as an indication that the pt has conductive hearing loss of the left ear?
Air conduction is less than bone conduction in the left ear
Using a blood pressure cuff that is too small may result in
An inaccurately high reading
A nurse is completing an informed consent document for a 16 yr old girl who is married and is scheduled for an emergency appendectomy. Which of the following actions should the nurse take?
Ask the client if they understand the providers plan for the appendectomy
Propioception
Awareness of the position of the body
A nurse is preparing to administer an intermittent tube feeding to a client who has a gastrostomy tube. Which of the following actions should the nurse take first?
Check the pH of the clients stomach contents
A nurse is caring for a pt who has acute renal failure. Which of the following assessments provides the most accurate measure of the pt fluid status?
Daily weight
A nurse is reviewing lab values of a pt who has a positive Chvosteks sign. Which of the following lab findings should the nurse expect?
Decreased calcium
a nurse is caring for pt who is producing large amounts of urine. the nurse should document this finding as which of the following?
Diuresis
When caring for a pt who has an NG tube for intermittent enteral feedings. Which of the following actions should the nurse take?
Elevate the head of the pt bed to 45 degrees before the feeding
A nurse is working with the facility's language interpreter to explain a wound care procedure to a pt who does not speak the same language as the nurse. Which of the following actions should the nurse take when describing the procedure to the pt?
Ensure the interpreter and the client speak the same dialect
How often do you remove wrist restraints?
Every 2 hours
What intervention should a nurse use when speaking w a pt who has a hearing impairment?
Face the pt when speaking
A nurse should recognize that which of the following findings places a pt at risk of impaired skin integrity?
Faint pedal pulses
A nurse is teaching a client about lifestyle changes to manage a chronic illness. Which of the following strategies should the nurse use first to help the client make a commitment to these lifestyle changes?
Help the pt identify ways that these changes will result in positive personal outcomes
A nurse is teaching a client who has a new hearing aid. Which of the following statements by the client indicates to the nurse an understanding of the teaching?
I will reinsert the hearing aid if i hear a whistling sound
A nurse is planning care for a client who is postoperative. Which of the following interventions should the nurse include in the plan to decrease the clients risk for venous stasis?
Instruct the client to elevate her legs when sitting in a chair
A nurse in a providers office is measuring a pt and notes a loss in height from the previous year. The nurse should identify this finding as a manifestation of which of the following musculoskeletal system disorders?
Osteoporosis
A nurse is reviewing a clients ABG lab results. Which of the following ABG results should the nurse report to the provider?
PaCO2 32 mm Hg
A nurse is admitting a client to an acute care facility. Which of the following actions by the nurse promotes client self-determination?
Providing the client with information about end of life decision making
Which of the following should alert the nurse that the pt has developed delirium?
Reduced level of consciousness
The kidneys regulate body fluids as well as assisting with which of the following functions?
Regulation of acid base balance
Fowler's position
Sitting upright
500 to 600 mL of fluid loss occurs each day through which organ?
Skin
What should a nurse do when performing trach care for a pt
Soak the inner cannula of the trach tube in normal saline
A nurse is caring for a client who is recovering from a stroke and tells the nurse he is concerned about paying his medical bills. The nurse should refer the client to which of the following members of the inter professional health care team?
Social worker
Which lab value can cause confusion?
Sodium 123 meq/L
A nurse is caring for a pt who has a cuffed endotracheal tube in place. The nurse should identify that the purpose of inflating the cuff includes which of the following?
Stabilizing the position of the tube, preventing aspiration of secretions, preventing air leaks
A nurse is caring for a pt who has xerostomia with a lack of saliva. Which of the following nutrients will be affected by the lack of salivary amylase?
Starch
A nurse instructs a client to keep his eyes closed, places an object in his hands, and asks him to identify the object. Which of the following abilities is the nurse evaluating with this technique?
Sterognosis
Which of the following findings should be a nurses priority? Heart rate 105, soft non tender abdomen, temp of 102.6 F, or overdue menses by 2 days
Temp of 102.6 F
When providing oral care to an unconscious client what should the nurse do
Test for the presence of the pt gag reflex
Stereognosis
The ability to identify an objects size, shape, and texture via tactile sensation
What should the nurse do when applying a vest restraint?
Tie the restraint with a quick release knot
A nurse is repositioning a client in bed. Which of the following actions should the nurse take when using ergonomic principles to move the client?
Tighten the abdominal muscles
A nurse is administering an IM injection to a 5 month old. Which of the following injection sites should the nurse use?
Vastus lateralis
a nurse on an oncology unit receives report at the beginning of her shift about 4 pt who are postoperative. which of the following pt should she see first?
a pt who is 2 days postoperative following a colectomy due to colorectal cancer and has an ostomy bag full of bright red bloody drainage
a nurse is caring for a pt who is receiving total parenteral nutrition. which of the following actions should the nurse take?
check the pt capillary blood glucose level every 4 hours
a nurse is collecting a urine specimen for culture and sensitivity for a pt who has a UTI. the pt has an indwelling cath . which of the following actions should the nurse take?
clamp the tubing below the collection port
a nurse is caring for a pt who had. a masectomy and has a self suction drainage evacuator in place. which of the following actions should the nurse take to ensure proper operation of the device?
collapse the device to remove air after emptying
during a physical exam the nurse suspects strabismus. which of the following tests should the nurse use to collect additional data?
corneal light reflex
fowlers position
head of bed elevated 45 degrees and knees slightly flexed
a nurse is preparing to administer an otic antibiotic to an adult client who has otitis media. which of the following actions should the nurse plan to take?
hold the dropper 1 cm above the ear canal during administration
a nurse is caring for a client who has a gastric ulcer. the nurse should explain that prolonged exposure of the body to stress can also cause which of the following to occur?
hyperglycemia
the pt states, "you are not putting that hose down my throat" which of the following statements should the nurse make?
i can see that this is upsetting you
a nurse is reviewing the use of side rails with an AP. which of the following statements by the AP indicates that further teaching is required?
if the pt seems confused, ill raise all 4 side rails so that he doesn't hurt himself
A nurse is instructing a pt about collecting a 24 hr urine specimen for creatinine clearance. Which of the following statements should the nurse identify as an indication that the pt understands the procedure?
ill make sure to keep the collection bottle in the container of ice they gave me
a nurse is assessing a pt who reports nausea and vomiting for 2 days. which of the following findings should indicate to the nurse that the pt is experiencing fluid volume deficit?
increased heart rate
which of the following foods should the nurse include as an example of an incomplete protein?
lentils
a nurse is planning care for a pt who has anorexia and nausea due to cancer tx. which of the following interventions should the nurse include?
limit drinking liquids with food
the nurse should use percussion to evaluate which of the following body part?
lungs
prone position
lying on the abdomen
which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation?
montgomery straps
a nurse is using the braden scale to predict the pressure ulcer risk of a client in a long term care facility. using this scale, which of the following parameters should the nurse evaluate?
nutrition
a nurse is caring for an older adult pt who has dysphagia following a cerebrovascular accident. which of the following actions should the nurse take when assisting the pt at mealtime?
offer the pt tart or sour foods first
a middle adult pt tells the nurse "i feel so useless now that my children do not need me anymore" which of the following responses should the nurse make?
people in middle adulthood often find satisfaction in nurturing and guiding young people
a nurse is preparing to remove an NG tube for a pt who had a partial colectomy. which of the following actions should the nurse take?
pinch the NG tube while removing the tube
a nurse is caring for a pt who reports feeling a pop after coughing without properly splinting an. abdominal incision. on assessment, the nurse notes that the pt wound has eviscerated. which of the following actions should the nurse take?
place the pt in a supine position with the hips and knees flexed, cover the wound and intestine with a sterile moistened dressing, monitor the pt for manifestations of shock
a nurse is performing suctioning for a pt who has a trach. which of the following actions should the nurse take?
pull suction catheter back 1 cm if the pt starts coughing
a nurse is planning to perform passive range of motion exercises for a client. which of the following actions should the nurse take?
repeat each joint motion 5 times during each session
a nurse is caring for a pt who is in the terminal stage of cancer. which of the following actions should the nurse take when she observes the pt crying?
sit and hold the pt hand
what position should a pt be in for an abdominal assessment?
supine
a home health nurse is completing an admission assessment of an older adult. client who has their caregiver present. which of the following findings should the nurse identify as a potential indication of elder abuse?
the caregiver insists on remaining in the room
Pt appears upset and refuses to take the medication before throwing the pill on the floor. which of the following entries should the nurse enter into the pt medical record?
the pt threw the medication on the floor
a nurse is preparing to administer an intramuscular injection to a young adult pt. which of the following injection sites is the safest for this pt?
ventrogluteal
a nurse is assessing a pt respiratory system. which of the following breath sounds should the nurse expect to hear over the periphery of the major lung fields?
vesicular
which of the following breath sounds should the nurse expect to hear over the periphery of the major lung fields?
vesicular
a nurse is caring for a pt who has a deficiency of vit D. which of the following foods should the nurse recommend the pt include in his diet?
whole milk