Fundamentals CMS Midterm
A nurse is performing an admission assessment on a client. The nurse determines the clients radial pulse rate is 68/min and the simultaneous apical pulse rate is 84/min what is the clients post deficit?
16/ min
A newly licensed nurse is reporting to the charge nurse about the care she gave to a client. She states, "the client said his leg pain was back, so I checked his medical record, and he last received his pain medication six hours ago. The prescription reads every four hours PRN for pain, so I decided he needs it. I asked the unit nurse to observe me preparing and administering it. I checked with the client 40 minutes later, and he said his pain is going away." The charge nurse should inform the newly licensed nurse that she left out which of the following steps of the nursing process?
A
A nurse is caring for a client who asks what her Snellen eye test results mean. The clients visual acuity is 20/30. Which of the following responses should the nurse make? A. Your eyes see at 20 ft what visually unimpaired eyes see at 30 ft B. Your right eye can see the chart clearly at 20 ft, and your left eye can see the chart clearly at 30 ft. C. Your eyes see at 30 ft what usually unimpaired eyes see at 20 ft D. Your left eye can see the chart clearly at 20 ft, and your right eye can see the chart clearly at 30 ft
A
A nurse is instructing an AP about caring for a client who has a low platelet count as a result of chemotherapy. Which of the following instructions is the priority for measuring vital signs for this client? A. Do not measure the clients temperature rectally B. Count the clients radial pulse for 30 seconds and multiply it by two C. Do not let the client know you are counting her respirations D. Let the client rest for five minutes before you measure her blood pressure
A
A nurse is talking with parents of a 12-year-old child. Which of the following issues verbalized by the parents should the nurse identify as a priority? A. We just don't understand why our son can't keep up with the other kids in simple activities like running and jumping. B. Our son keeps trying to find ways around our household rules. He always wants to make deal with us. C. We think our son is trying to hard to excel in math just to get the top grades in his class D. Our son is always afraid the kids in school will laugh at him because he likes to sing.
A
A nurse in a providers office is preparing to auscultate and percuss a clients abdomen as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply) A. Tympany B. High-pitched clicks C. Borborygmi D. Friction rubs E. Bruits
A B
A nurse is collecting data from an older adult client as part of a neurosensory examination. Which of the following findings should the nurse expect as changes associated with aging? (Select all that apply) A. Slower light touch sensation B. Some vision and hearing decline C. Slower fine finger movement D. Some short-term memory decline E. Decreased risk of depression
A B C D
A nurse is reviewing CDC immunization recommendations with a young adult client. Which of the following vaccines should the nurse recommend as routine, rather than catch-up, during young adulthood? (Select all that apply) A. Influenza B. Measles, mumps, rubella C. Pertussis D. Tetanus E. Polio
A C D
A nurse is caring for multiple clients during a mass casualty event. Which of the following clients is the priority?
A client who has partial-thickness and full-thickness burns to his face neck and chest
A nurse is caring for a group of clients on a medical surgical unit. For which of the following client care needs should the nurse initiate a referral for a social worker? (Select all that apply)
A client who has terminal cancer requests hospice care in her home. A client asks about community resources available for older adults. A client requests an electric wheelchair for use after discharge.
A nurse is instructing a group of nursing students about how to know and what to expect when ethical dilemmas arise. Which of the following situations should the students identify as an ethical dilemma?
A family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill
A nurse on a medical-surgical unit is admitting a client. Which of the following information should the nurse document in the client's record first?
A) Assessment
A nurse is planning weight loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the client's commitment to a long-term goal of weight loss?
A) Attempt to increase the clients self motivation
A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first?
A) evaluate pedal pulses
A nurse is admitting a client who has a cholecystitis to a medical surgical unit. Which of the following actions are essential steps of the admission procedure? (Select all that apply)
A. Explain the roles of other care delivery staff B. Begin discharge planning D. Document the clients wishes about organ donation E. Introduce the client to his roommate
A nurse in the clinic is planning health promotion and disease prevention strategies for a client who has multiple risk factors for cardiovascular disease. Which of the following interventions should the nurse include? (Select all that apply)
A. Help the client see the benefits of her actions B. Identify the clients support systems C. Suggest and recommend community resources E. Teach stress management strategies
A nurse in a providers office is collecting data from the mother of a 12 month old infant. The client states that her son is old enough for toilet training. Following an educational session with the nurse, the client now states that she will postpone toilet training until her son is older. Learning has occurred in which of the following domains?
Affective
A charge nurse is assigning rooms for the clients to be admitted to the unit. To prevent falls, which of the following clients just the nurse assigned to the room closest to the nurses station?
An older adult who is postoperative following a below the knee amputation
A nurse is evaluating how well a client learned the information he presented in an instructional session about following a heart-healthy diet. The client states that she understands what to do now. Which of the following actions should the nurse take to evaluate the clients learning?
Ask the client to explain how to select or prepare meals.
A nurse observes an AP reprimanding a client for not using the urinal properly. The AP tells him she will put a diaper on him if he does not use the urinal more carefully next time. Which of the following torts is the AP committing?
Assault
A nurse is caring for a client who decides not to have surgery despite significant blockages in his coronary arteries. The nurse understands that this clients choice is an example of which of the following ethical principles?
Autonomy
A nurse is caring for a client who states, "I have to check with my wife and see if she thinks I am ready to go home." The nurse replies, "how do you feel about going home today?" Which clarifying techniques is the nurse using to enhance communication with the client? A. Pacing B. Reflecting C. Paraphrasing D. Restating
B
A nurse is caring for a school age child who is sitting in a chair. To facilitate effective communication, which of the following actions should the nurse take? A. Touch the child's arm B. Sit at eye level with the child C. Stand facing the child D. Stand with a relaxed posture
B
A nurse is collecting data for a clients comprehensive physical examination. After the nurse inspects the clients abdomen, which of the following skills of the physical examination process should she perform next? A. Olfaction B. Auscultation C. Palpation D. Percussion
B
A nurse is counseling a middle adult client who describes having difficulty dealing with several issues. Which of the following client statements should the nurse identify as a priority to assess further? A. I am struggling to except that my parents are aging I need so much help B. It's been so stressful for me to think about having intimate relationships C. I know I should volunteer my time for a good cause, but maybe I'm just selfish D. I love my grandchildren, but my son expects me to relive my parenting days
B
A nurse is performing and integumentary assessment for a group of clients. Which of the following findings should the nurse recognize as requiring immediate intervention? A. Pallor B. Cyanosis C. Jaundice D. Erythema
B
A nurse is talking with a parent who is concerned about several issues with her preschooler. Which of the following issues should the nurse identify as a priority? A. My son mimics my husband getting dressed B. My son has temper tantrum's every time we tell him to do something he doesn't want to do C. I think my son truly believes that his toys have personalities and talk to him D. I feel bad when I see my son trying so hard to button his shirt
B
A nurse is teaching a young adult client about health promotion and illness prevention. Which of the following statements by the client indicates an understanding of the teaching? A. I already had my immunizations as a child, so I'm protected in that area. B. It is important to schedule routine healthcare visits even if I'm feeling well C. I will just go to an urgent care center for my routine medical care D. There's no reason to seek help if I am feeling stressed because it's just part of life
B
A nurse received a prescription for an antibiotic for a client who has cellulitis. The nurse checks the clients medical record, discovers that she is allergic to the anabiotic, and calls the provider to request a prescription for a different antibiotic. Which of the following critical thinking attitudes did the nurse demonstrate?
B
A nurse who is admitting a client who has a fractured femur obtains a blood pressure reading of 140/94 mmHg. The client denies any history of hypertension. Which of the following actions should the nurse take? A. Request a prescription for an anti-hypertensive medication B. Ask the client if she is having pain C. Request a prescription for an anti-anxiety medication D. Return in 30 minutes to recheck the clients blood pressure
B
Which of the following strategies should a nurse use to establish a healthy relationship with a client? A. Make sure the communication is equally reciprocal between the nurse and the client B. Encourage the client to communicate his thoughts and feelings C. Give the nurse-client communication no time limits D. Allow communication to occur spontaneously throughout the nurse-client relationship
B
A nurse is reviewing the CDC's immunization recommendations with the parents of an adolescent. Which of the following recommendations should the nurse include in this discussion? (Select all that apply) A. Rotavirus B. Varicella C. Herpes zoster D. Human papilloma virus E. Seasonal influenza
B D E
A home health nurse is discussing the dangers of food poisoning with a client. Which of the following information should the nurse include in her counseling? (Select all that apply)
B. Immunocompromised individuals are at risk for complications from food poisoning C. Clients who are at high-risk should eat or drink only pasteurized dairy foods E. Handling raw and fresh food separately can prevent food poisoning
The mother of a 7-month old infant tells the nurse at the pediatric clinic that her baby has been fussy with occasional loose stools since she started feeding him fruits and vegetables. Which of the following responses shiould the nurse make? (Select all that apply)
B. Let's make a list of the food he is eating so we can spot any problems. C. Did the changes begin after you started one particular food? D. Has he been vomiting since he started these new foods?
A nurse educator is discussing the facility protocol in the event of a tornado with the staff. Which of the following should the nurse include in the instructions? (Select all that apply)
B. Place blankets over clients who are confined to bed C. Move beds away from the windows D. Draw shades and close drapes
A nurse is contributing to the plan of care for a client who has been admitted to the facility with a suspected diagnosis of pertussis. Which of the following intervention should the nurse include in the plan of care? (Select all that apply)
B. Wear a mask when providing care within 3 ft of client C. Place a surgical mask on the client if transportation to another department is unavoidable E. Wear a gown when performing care that might result in contamination from secretions.
A nurse is equating a group of newly licensed nurses with the roles of the various members of the healthcare team they will encounter on a medical surgical unit. When she gives examples of the types of tasks CNAs may perform which of the following client activities should she include? (Select all that apply)
Bathing Ambulating Toileting Measuring vital signs
A nurse offers pain medication to a client who is postoperative prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles?
Beneficence
A nurse is preparing information for a change of shift report; which of the following information should the nurse include in the report?
Bone scan scheduled for today
An occupational health nurse is caring for an employee who was exposed to an unknown dry chemical, resulting in a chemical burn. Which of the following interventions should the nurse include in the plan of care?
Brush the chemical off the skin and clothing
A charge nurse is explaining the various stages of the lifespan to a group of newly licensed nurses. Which of the following examples should the charge nurse include as a developmental task for a young adult? A. Becoming actively involved in providing guidance to the next generation B. Adjusting to major changes in roles and relationships due to losses C. Devoting a great deal of time to establishing an occupation D. Finding oneself "sandwiched" between and being responsible for two generations
C
A nurse in a family practice clinic is performing a physical examination of an adult client. Which part of her hands should she use during palpation for optimal assessment of skin temperature? A. Palmar surface B. Fingertips C. Dorsal surface D. Base of the fingers
C
A nurse is caring for a client who reports pain with internal rotation of her right shoulder. This discomfort can affect the clients ability to perform which of the following activities? A. Mopping her floors B. Brushing the back of her hair C. Fastening her bra behind her back D. Reaching into a cabinet above her sink
C
A nurse is counseling a young adult who describes having difficulty dealing with several issues. Which of the following client statements to the nurse identify as a priority to assess further? A. I have my own apartment now, but it's not easy living away from my parents B. It's been so stressful for me to even think about having my own family C. I don't even know who I am yet, and now I'm supposed to know what to do. D. My girlfriend is pregnant and I don't think I have what it takes to be a good father.
C
A nurse is talking with an adolescent who is having difficulty dealing with several issues. Which of the following issues should the nurse identify as a priority? A. I kind of like this boy in my class, but he doesn't like me back B. I want to hang out with the kids in the science club, but the jocks pick on them. C. I am so fat, I skip meals to try to lose weight D. My dad wants me to be a lawyer like him, but I just want to dance.
C
A nurse is talking with the parents of a 10-year-old child who is concerned that her son is becoming secretive, such as closing the door when he showers, and dresses. Which of the following responses should the nurse make? A. Perhaps you should try to find out what he is doing behind those closed doors B. Suggest that he leave the door ajar for his own safety C. At this age children tend to become modest and value their privacy D. You should establish a disciplinary plan to stop this behavior
C
A nurse is teaching the father of a 12-year-old boy about manifestations of puberty. The nurse should explain that which of the following physical changes occurs first? A. Appearance of downy hair on the upper lip B. Hair growth in the axillae C. Enlargement of the testes and scrotum D. Deepening of the voice
C
During an abdominal examination, a nurse and providers office determines that a client has abdominal distention. The protrusion is at midline, the skin over the area is tot, and the nurse notes no involvement of the flanks. Which of the following possible causes of distention should the nurse suspect? A. Fat B. Fluid C. Flatus D. Hernias
C
A nurse is performing a head and neck examination for an older adult client. Which of the following age related findings should the nurse expect? (Select all that apply) A. Reddened gums B. Lowered vocal pitch C. Tooth loss D. Glare intolerance E. Thickened eardrums
C D E
A nurse is caring for a client who is in the terminal stage of cancer. Which of the following actions should the nurse take when she observes the client crying?
C) Sit and hold the clients hand
A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching.
C) Sit on the toilet 30 minutes after eating a meal
A nurse is planning diversionary activities for toddlers on an inpatient unit. Which of the following activities should the nurse include? (Select all that apply)
C. Filling and emptying containers D. Playing with blocks E. Looking at books
A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? (Select all that apply)
C. Make sure that the clients call light is within reach D. Provide the client with nonskid footwear E. Complete a fall-risk assessment
A nurse is providing preoperative education for a client who will undergo a mastectomy the next day. Which of the following statements should the nurse identify as an indication that the client is ready to learn?
Can you tell me about how long the surgery will take?
A nurse manager is developing strategies to care for the increasing number of clients who have obesity. Which of the following actions should the nurse include as a primary healthcare strategy?
Collaborating with providers to perform obesity screenings during routine office visits.
A nurse is caring for a client who has a history of falls. Which of the following actions is the nurses priority?
Complete a fall-risk assessment
A nurse instructor is explaining the various stages of the life span to a group of nursing students. Which of the following examples should the nurse include as a developmental task for middle adulthood? A. The client evaluates his behavior after a social interaction B. The client states he is learning to trust others C. The client wishes to find meaningful friendships D. The client expressed his concerns about the next generation
D
A nurse is assessing a clients Nuro sensory system. To evaluate stereognosis, the nurse should ask the client to close his eyes and identify which of the following items? A. A word she whispers 30 cm from his ear B. A number she traces on the palm of his hand C. The vibration of a tuning fork she places on his foot D. A familiar objects she places in his hands
D
A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection?
D
A nurse is counseling an older adult who describes having difficulty dealing with several issues. Which of the following problems verbalized by the client should the nurse identify as a priority? A. I spent my whole life dreaming about retirement, and now I wish I had my job back. B. It's been so stressful for me to have to depend on my son to help around the house C. I just heard my friend Al died. That's the third one in 3months. D. I keep forgetting which medications I have taken during the day
D
A nurse is evaluating teaching about nutrition with the parents of an 11-year-old child. Which of the following statements should indicate to the nurse an understanding of the teaching? A. She wants to eat as much as we do, but we're afraid she'll soon be overweight B. She skips lunch sometimes but we figure it's ok as long as she has a healthy breakfast and dinner C. We limit fast food restaurant meals to three times a week now D. We reward her school achievements with a point system instead of pizza or ice cream
D
A nurse is planning to obtain the vital signs of a 2 year old child who is experiencing diarrhea and who might have a right ear infection. Which of the following routes should the nurse use to obtain the temperature?
D) Temporal
A home health nurse is discussing the dangers of carbon monoxide poisoning with a client. Which of the following information should the nurse include in her counseling?
D. Carbon monoxide binds with hemoglobin in the body
A nurse is caring for a 20-year-old client who is sexually active and has come to the college health clinic for a first time check up. Which of the following interventions should the nurse perform first to determine the clients need for health promotion and disease prevention?
Determine risk factors
A nurse is caring for a client who is sitting in a chair and asked to return to bed. Which of the following actions is the nurse's priority at this time?
Determine the clients ability to help with the transfer
A nurse uses a head-to-toe approach to conduct a physical assessment of a client who undergoes surgery the following week. Which of the following critical thinking attitudes did the nurse demonstrate?
Discipline
A nurse is discussing the purpose of regulatory agencies during a staff meeting. Which of the following tasks should the nurse identify as a responsibility of state licensing boards?
Ensuring that healthcare providers comply with regulations
A nurse is teaching the parents of a toddler about discipline. Which of the following actions should the nurse suggest?
Establish consistent boundaries for the toddler
A nurse is caring for a competent adult client who tells the nurse that he's thinking about leaving the hospital against medical advice. The nurse believes that this is not in the clients best interest, so she prepares to administer a PRN sedative medication the client has not requested along with his usual medication. Which of the following types of tort is the nurse about to commit?
False imprisonment
A nurse at a providers office is talking about routine screenings with a 45-year-old female client who has no specific family history of cancer or diabetes mellitus. Which of the following client statements indicates that the client understands how to proceed?
For now I should continue to have a mammogram each year.
A nurse is talking with the parent of a 4-year-old child who states that his child is waking up at night with nightmares. Which of the following investigations should the nurse suggest?
Have the child take an afternoon nap
A nurse is caring for a client who presents with linear clusters of fluid-containing vesicles with some crustings. The nurse should identify the client has manifestations of which of the following conditions?
Herpes zoster
A nurse is discussing restorative Health care with a newly licensed nurse. Which of the following examples should the nurse include in the teaching? (Select all that apply).
Home health care Rehabilitation facilities Skilled nursing facilities
A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have which of the following?
Hypotension
Place in order: Inspection Palpation Percussion Auscultation
Inspection, Auscultation, Palpation, Percussion
A nurse is explaining the various levels of healthcare services to a group of newly licensed nurses. Which of the following examples of care or care settings should the nurse classify as tertiary? (Select all that apply)
Intensive care unit (ICU) Oncology treatment center Burn center
A nurse is instructing a group of nursing students about the responsibilities organ donation and procurement involve. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the nurse should understand that this aspect of care delivery is an example of which of the following ethical principles?
Justice
A nurse is caring for a client who has a new prescription for antihypertensive medication. Prior to administering the medication, the nurse uses an electric database to gather information about the medication and the effects it might have on this client. Which of the following components of critical thinking is the nurse using when he reviews the medication information?
Knowledge
A nurse is caring for a client who is about to undergo an elective surgical procedure. The nurse should take which of the following actions regarding informed consent? (Select all that apply)
Make sure the surgeon obtained the clients consent Witness the client signature on the consent form
A nurse is explaining the various types of health care coverage clients might have to a group of nursing students. Which of the following healthcare financing mechanisms are federally funded? (Select all that apply).
Medicare Medicaid
A nurse observes smoke coming from under the door of the staff lounge. Which of the following actions is the nurses priority?
Move clients who are nearby
A nurse is cautioning the mother of an eight month old infant about safety. Which of the following statements by the mother indicates an understanding of safety for the infant?
My baby loves to play with his crib gym, but I took it away from him
A nurse questions a medication prescription as too extreme in light of the clients advanced age and unstable status. The nurse understands that this action is an example of which of the following ethical principles?
Nonmaleficence
A nurse is talking with a client who recently attended a cholesterol screening event and a heart-healthy nutrition presentation at a neighborhood center. The clients total cholesterol was 248 mg/dL. After seeing the provider, the client started taking medication to lower his cholesterol level. The client was later hospitalized for severe chest pain, and subsequently enrolled in a cardiac rehabilitation program. Which of the following activities for the client is an example of primary prevention?
Nutrition presentation
A goal for a client who has difficulty with self-feeding due to rheumatoid arthritis is to use adaptive devices. The nurse caring for the client should initiate a referral to which of the following members of the interprofessional care team?
Occupational therapist
A nurse educator is conducting a parenting class for new parents of infants. Which of the following statements made by a participant indicates understanding of the instructions?
Once my infant starts to push up, I will remove the mobile from over the crib.
When entering a clients room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. Which of the following actions should the nurse take when preparing the sterile field?
Place a mask on the client to limit the spread of microorganisms into the surgical wound
A nurse is reviewing car seat safety with the parents of a 1-month old infant. When reviewing car seat use, which of the following instruction should the nurse include?
Position the car seat so that the infant is rear-facing
A client who is postoperative following knee arthroplasty is concerned about the adverse effects of the medication he is receiving for pain management. Which of the following members of the interprofessional care team can assist the client in understanding the medications affects? (Select all that apply)
Provider Pharmacists Registered Nurse
A nurse manager of a medical surgical unit is assigning care responsibilities for the oncoming shift. A client is awaiting transfer back to the unit from the PACU following thoracic surgery. To which of the following staff members should the nurse assigned the client?
RN
A nurse on a medical surgical unit has received change of shift report and will care for four clients. Which of the following clients needs should the nurse assigned to an AP?
Reapplying a condom catheter for a client who has urinary incontinence.
By the second postoperative day a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process?
Reassess the client to determine the reasons for an adequate pain relief
A nurse has noticed several occasions in the past week on another nurse on the unit seem drowsy and unable to focus on the issue at hand. Today, she found the nurses sleep in a chair in the break room when she was not on a break. Which of the following actions should the nurse take?
Report the observation to the nurse manager on the unit
A nurse is caring for a client who is receiving enteral tube feedings due to dysphasia. Which of the following bed position should the nurse cues for safe care of this client?
Semi-Fowler's
A nurse is completing discharge instructions for a client who has COPD. The nurse should identify that the client understands the orthopneic position when she states that she will do which of the following when she has difficulty breathing at night?
Sit on the side of her bed and rest her arms over pillows on top of her bedside table
A client who has had a CVA (cerebrovascular accident) has persistent problems with dysphasia. The nurse caring for the client should initiate a referral with which of the following members of the interprofessional team?
Speech-language pathologist
An RN is making assignments for a PN at the beginning of the shift which of the following assignments should the PN question?
Teaching a client who has asthma to use a metered dose inhaler
A nurse in a health clinic is caring for a 21-year-old client who reports a sore throat. The client tells the nurse that he has not seen a doctor since high school. Which of the following health screenings should the nurse expect the provider to perform for this client?
Testicular examination
A nurse is observing a client drawing up and mixing insulin. Which of the following findings should the nurse identify as an indication that psychomotor learning has taken place?
The client is able to demonstrate the appropriate technique
A nurse is preparing an instructional session for an older adult about managing stress incontinence. Which of the following actions should the nurse take when first meeting with the client?
The client is able to demonstrate the appropriate technique
A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation of an invasive procedure. Which of the following flaps should the nurse unfold first?
The flap farthest from the body
A mother tells the nurse that her two-year-old toddler has temper tantrum's and says "no" every time the mother tries to help her get dressed. The nurse should recognize, the toddler is manifesting which of the following stages of development?
Trying to increase her independence
A nurse is performing an admission assessment for an older adult client. After gathering the assessment data and performing the review of systems, which of the following actions is a priority for the nurse?
orient a client to his room
A nurse is discussing the HIPAA Privacy rule with nurses during new employee orientation. Which of the following information should the nurse include? (Select all that apply)
~Family members should provide a code prior to receiving client health information ~Communication of client information can occur at the nurses station. ~A client can request a copy of the medical record ~A nurse my photo copy a clients medical record for transferred to another facility.
A nurse is performing a Neurosensory examination for a client. Which of the following assessment should the nurse perform to test the clients balance? (Select all that apply) A. Rhomberg test B. Heal-to-toe walk C. Snellen test D. Spinal accessory function E. Rosenbaum test
A B
Which of the following actions should the nurse take when using the communication technique of active listening? (Select all that apply) A. Use an open posture B. Write down what the client says to avoid forgetting details C. Establish and maintain eye contact D. Nod in agreement with the client throughout the conversation E. Respond positively when giving feedback
A C E
A nurse in a providers office is preparing to assess a clients skin as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply) A. Capillary refill less than 3 seconds B. 1+ pitting edema in both feet C. Pale nail beds in both hands D. Thick skin on the soles of the feet E. Numerous light brown mascules on the face
A D E
A nurse in a providers office is preparing to perform a breast examination for an older adult client who is post menopausal. Which of the following findings should the nurse expect? (Select all that apply) A. Smaller nipples B. Less adipose tissue C. Nipple discharge D. More pendulous E. Nipple inversion
A D E
A nurse is assessing a clients thyroid gland as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply) A. Palpating the thyroid in the lower half of the neck B. Visualizing the thyroid on inspection of the neck C. Hearing a bruit when auscultating the thyroid D. Feeling the thyroid ascend as the client swallows E. Finding some metric extension of the trachea on both sides of the midline
A D E
A nurse is teaching a group of older adults about expected changes of aging. Which of the following statements by a group member indicates that the teaching has been effective?
A) I should expect my heart rate to take longer to return to normal after exercise as I get older
A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning self-injection of insulin. Which of the following statements should the nurse make?
A) Tell me what I can do to help you overcome your fear of giving yourself injections
A nurse is providing teaching to a client who has heart failure about how to reduce his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits?
A) The involvement of the client in planning the change
A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching?
A) There are times I should use soap and water rather than an alcohol-based hand rub to clean my hands
A nurse is recieving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse make to transfer the client from the stretcher to the bed?
A) lock the wheels on the bed and stretcher
A nurse educator is reviewing was a newly hired nurse the difference in manifestations of a localized versus a systemic infection. The nurse indicates understanding when she states that which of the following are manifestations of a systemic infection? (Select all that apply)
A-Fever B-Malaise E-Increase in pulse and respiratory rate
A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data? (Select all that apply)
A-Respiratory rate is 22/min with even, unlabored respirations. D-Skin is pink, warm, and dry E-The AP reports the client walked with a limp
A nurse is assessing an older adult client who has significant tenting of the skin over his forearm. Which of the following factors should the nurse consider as a cause for this finding? (Select all that apply) A. Thin, parchment-like skin B. Loss of adipose tissue C. Dehydration D. Diminished skin elasticity E. Excessive wrinkling
B C D
A nurse is planning a presentation for a group of older adults about health promotion and disease prevention. Which of the following interventions should the nurse plan to recommend? (Select all that apply) A. Human papilloma virus (HPV) immunization B. Pneumococcal immunization C. Yearly eye examination D. Periodic mental E. Annual fecal occult blood test
B C D E
A nurse is assessing postoperative circulation of the lower extremities for a client who had knee surgery. The nurse should include which of the following? (Select all that apply) A. Range of motion B. Skin color C. Edema D. Skin lesions E. Skin temperature
B C E
A nurse is collecting data to evaluate a middle adults psychosocial development. The nurse should expect middle adults to demonstrate which of the following developmental tasks? (Select all that apply) A. Develop an acceptance of diminished strength and increased dependence on others B. Spend time focusing on improving job performance C. Welcome opportunities to be creative and productive D. Commit to finding friendship and companionship E. Become involved with community issues and activities
B C E
A nurse is introducing herself to a client as the first step of a comprehensive physical examination. Which of the following strategies should the nurse use with this client? (Select all that apply) A. Address the client with the appropriate title and her last name B. Use a mix of open-and-closed ended questions C. Reduce environmental noise D. Have the client complete a printed history form E. Performed the general survey before the examination
B C E
During a cardiovascular examination, a nurse in a providers office places the diaphragm of the stethoscope on the left midclavicular line at the fifth intercostal space. Which of the following heart sounds is the nurse attempting to auscultate? (Select all that apply) A. Ventricular gallop B. Closure of the mitral valve C. Closure of the Paul Monic valve D. Closure of the tricuspid valve E. Murmur
B D
A nurse is assessing an adult clients internal ear canals with an otoscope as part of a head and neck examination. which of the following actions should the nurse take? (Select all that apply) A. Pull the auricle down and back B. Insert the speculum slightly down and forward C. Insert the speculum 2 to 2 1/2 cm (0.8 to 1 inch) D. Make sure the speculum does not touch the ear canal E. Use the light to visualize the Tympanic membrane in a cone shape.
B D E
A nurse is collecting data from an older adult client as part of a comprehensive physical examination. Which of the following findings should the nurse expect as associated with aging? (Select all that apply) A. Skin thickening B. Decreased height C. Increased saliva production D. Nail thickening E. Decreased bladder capacity
B D E
A nurse is caring for a client who is postoperative and has parlytic ileus. Which of the following abdominal assessments should the nurse expect?
B) Absent Val sounds with distention
A nurse is caring for a client who is concerned about his impending discharge home with a new colostomy because he is an avid swimmer. Which of the following statements should the nurse make? (Select all that apply) A. You will do great! You just have to get used to it. B. Why are you worried about going home? C. Your daily routines will be different when you get home. D. Tell me about your support systems you'll have after you leave the hospital. E. Let me tell you about a friend of mine with a colostomy who also enjoys swimming.
C D E
A nurse is providing teaching for an older adult client who has lost 4.5 kg (9.9 pounds) since his last admission six months ago. Which of the following instruction should the nurse include in the teaching? (Select all that apply) A. Eat three large meals a day B. Eat your meals in front of the television C. Eat foods that are easy to eat, such as finger foods D. Invite family members to eat meals with you E. Exercise every day to increase appetite
C D E
A nurse in a providers office is preparing to assess a young adult male client's musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (select all that apply) A. Concave thoracic spine posteriorly B. Exaggerated lumbar curvature C. Concave lumbar spine posteriorly D. Exaggerated thoracic curvature E. Muscles slightly larger on his dominant side
C E
A nurse in a providers office is preparing to auscultate and percuss a clients thorax as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply) A. Rhonchi B. Crackles C. Resonance D. Tactile fremitus E. Bronchovesicular sounds
C E
A nurse in a providers office is preparing to test a clients cranial nerve function. Which of the following directions should she include when testing cranial nerve V ? (Select all that apply) A. Close your eyes B. Tell me what you can taste C. Clinch your teeth D. Raise your eyebrows E. Tell me when you feel a touch
C E
A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take?
C) Administer analgesics to the child on a routine schedule throughout the day and night
A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take?
C) Carefully remove the gloves and follow with hand hygiene
A charge nurse is teaching adult cardiopulmonary resusciation (CPR) to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR?
C) Confirm unresponsiveness
A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which of the following actions should the nurse take?
C) Count the apical pulse rate for one full minute and describe the written in the chart
A nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take?
C) Raise the level of the bed
A nurse is performing skin assessments on a group of clients. Which of the following lesions should the nurse identify as vesicles? (Select all that apply) A. Acne B. Warts C. Psoriasis D. Herpes simplex E. Varicella (chickenpox)
D E
A nurse is caring for a client who is unstable and has vital signs measured every 15 min by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take?
D) Disconnect the machine, and measure the blood pressure manually every 15 min
A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported for the procedure, which of the following actions should the nurse take first?
D) Identify the client using to identifiers
A nurse in a surgeon's office is providing preoperative teaching for a client who is scheduled for surgery the following week. The client tells the nurse that he will prepare his advance directives before he goes to the hospital. Which of the following statements made by the client should indicate to the nurse an understanding of advance directives?
I plan to write that I dont want them to keep me on a breathing machine.
A nurse is discussing the nursing process with a newly hired nurse. Which of the following statements by the newly hired nurse should the nurse identify as appropriate for the planning step of the nursing process?
I will determine the most important client problems that we should address
A nurse manager is reviewing with nurses on the unit the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction?
I will go to the nurses station for assistance
A security officer is reviewing actions to take in the event of a bomb threat by phone to a group of nurses. Which of the following statements by a nurse indicates understanding of proper procedure?
I will listen for background noises
A nurse is reviewing nutritional guidelines with the parents of a two-year-old toddler. Which of the following parent statements should indicate to the nurse an understanding of the teaching?
I'll give my son about 2 tablespoons of each food at meal times
A nurse in a providers office is documenting his findings following an examination he performed for a client new to the practice. Which of the following parameters should he include as part of the general survey? (Select all that apply) A. Posture B. Skin lesions C. Speech D. Allergies E. Immunization status
A B C
A nurse is receiving a providers prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? (Select all that apply)
A-Repeat the details of the prescription back to the provider B-Have another nurse listen to the telephone prescription. C-Obtain providers signature on the prescription within 24 hours.
A nurse is talking with the parents of a six month old infant about gross motor development. Which of the following gross motor skills are expected findings in the next three months? (Select all that apply)
A-Rolls from back to front B-Bears weight on legs D-Sits unsupported
A nurse is giving a presentation about accident prevention to a group of parents of toddlers. Which of the following accident prevention strategies should the nurse include? (Select all that apply)
A-Store toxic agents in locked cabinets C-Turn pot handles toward the back of the stove D-Place safety gates across stairways
A nurse is discussing occurrences that require completion of an incident report with a newly licensed nurse. Which of the following should the nurse include in the teaching? (Select all that apply)
A-medication error B-needle sticks D-Omission of prescription
A nurse is assessing from a 2-week old newborn during a routine check-up. Which of the following findings should the nurse expect? (Select all that apply)
A-sleeps 14 to 16 hours each day D-hands remain in a closed position E-current weight same as birthweight
A nurse is caring for a client who had a stroke and is scheduled for transfer to a rehabilitation center. Which of the following tasks are the responsibility of the nurse at the transferring facility? (Select all that apply)
A. Ensure that the client has possession of his valuables B. Confirm that the rehabilitation center has a room available at the time of transfer D. Give a verbal transfer report via telephone E. Complete a transfer form for the receiving facility.
A nurse is caring for a client diagnosed with severe acute respiratory syndrome (SARS), the nurse is aware that healthcare professionals are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting? (Select all that apply)
A. Planning and evaluating control and prevention strategies B. Determining public health priorities C. Ensuring proper medical treatment E. Monitoring for common-source outbreaks
A nurse is reviewing safety precautions with a group of young adults at a community health fair. Which of the following recommendations should the nurse include, to address common health risks for this age group? (Select all that apply) A. Install bath rails and grab bars in bathrooms B. Wear a helmet while skiing C. Install a carbon monoxide detector D. Secure fire arms in a safe location E. Remove throw rugs from the home
B C D
A nurse is performing a comprehensive physical examination on an older adult client. Which of the following intervention should the nurse use in consideration of the clients age? (Select all that apply) A. Collect the data in one continuous session B. Plan to allow plenty of time for position changes C. Make sure the client has any essential sensory aids in place D. Tell the client to take her time answering questions E. Invite the client to use the bathroom before beginning the examination
B C D E
A nurse is caring for a client who has terminal illness. The client asks several questions about the nurse's religion beliefs related to death and dying. Which of the following actions should the nurse take?
B) Encourage the client to express his thoughts about death and dying
A nurse is preparing the discharge summary for a client who has had any arthroplasty and is going home. Which of the following information about the client should the nurse include in the discharge summary? (Select all that apply)
B-Follow up care C-Instructions for diet and medications E-Contact information for the home healthcare agency.
A nurse is preparing an in-service program about delegation. Which of the following elements should she identify when presenting the five rights of delegation? (Select all that apply)
B-Right supervision and evaluation C-Right direction and communication E-Right circumstances
A nurse is delegating the ambulation of a client who had knee arthroplasty five days ago to an AP. Which of the following information should the nurse share with the AP? (Select all that apply)
B-The client ambulates with his slippers on over his antiembolic stockings C-The client uses a front-wheeled walker when ambulating D-The client had pain medication 30 mins ago
A nurse is caring for a client who is 24 hr postoperative following abdominal surgery. The nurse suspects the clients acute pain management is inadequate. Which of the following data reinforce this suspicion? (Select all that apply)
B-The client is non-adherent with coughing, deep breathing, and dangling. C-The client may have pain medication every 4 to 6 hours, but accepts it every 6 to 7 hours. E-The client vital signs are heart rate 124/min, respiratory rate 22/min, temperature 37°C (98°F), and blood pressure 156/80 mm Hg
A nurse is reviewing hand hygiene techniques with a group of AP. which of the following instructions should the nurse include when discussing handwashing? (Select all that apply)
B-Wash hands with soap and water for at least 15 secs D-Use a clean paper towel to turn off hand faucets
A nurse is reviewing documentation with a group of newly licensed nurses. Which of the following legal guidelines should be followed when documenting in a clients record? (Select all that apply)
B-put the date and time on all entries C-document objective data leaving out opinions
A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field? (Select all that apply)
B. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field C. The procedure is delayed one hour because the provider receives an emergency call D. The nurse turns to speak to someone who enters through the door behind the nurse
A nurse on a medical surgical unit is informed that a mass casualty event occurred in the community and that it is necessary to discharge stable clients to make beds available for injury victims. Which of the following clients should the nurse recommend for discharge? (Select all that apply)
C. A client who is scheduled for elective surgery D. A client who has chronic hypertension and blood
A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects can the nurse touch without breaching sterile technique? (Select all that apply)
C. The inner wrapping of an item on the sterile field D. An irrigation syringe on the sterile field E. One gloved hand with the other gloved hand
A nurse is preparing to administer medications to a preschooler. Which of the following strategies should the nurse implement to increase the child's cooperation in taking medications? (Select all that apply) A. Reassure the child an injection will not hurt B. Mix oral medications in a large glass of milk C. Offer the child choices when possible D. Have the parents bring in a favorite toy from home E. Engage the child in pretend play with a toy medical kit
D E
A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse with inspiration. The nurse auscultates a high-pitched scratching sound during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document?
D) Pericardial friction rub
As part of the admission process, a nurse at a long-term care facility is gathering a nutrition history for a client who has dementia. Which of the following components of the nutrition evaluation is the priority for the nurse to determine from the clients family?
D-Any difficulty swallowing
A nurse is instructing a group of nursing students in measuring a clients respiratory rate. Which of the following guidelines should the nurse include? (Select all that apply) A. Place the client in semi-Fowler's position B. Have the client rest an arm across the abdomen C. Observe one for respiratory cycle before counting the rate D Count the rate for 30 seconds if it is irregular E. Count and report any sighs the client demonstrates
A B C
A nurse is planning diversionary activities for school-age children on an inpatient pediatric unit. Which of the following activities should the nurse include? (Select all that apply) A. Building models B. Playing video games C. Reading books D. Using toy carpentry tools E. Playing board games
A B C
A nurse is preparing a wellness presentation for families about health screening for adolescents. Which of the following information should the nurse include? (Select all that apply) A. Obtain a periodic mental status evaluation B. Discuss prevention of sexually transmitted infections C. Regularly screen for tuberculosis D. Provide education about drug and alcohol use E. Teach monthly breast examinations for girls
A B C D
A nurse is planning a health promotion and primary prevention class for the parents of school age children. Which of the following information should the nurse include? (Select all that apply) A. Provide information about the risk of childhood obesity B. Discuss the danger of substance use disorders C. Promote discussion about sexual issues D. Recommend the school age child sit in the front seat of the car E. Reinforce stranger awareness
A B C E
A nurse in the pediatric unit is caring for an adolescent who has multiple fractures. Which of the following interventions should the nurse take? (Select all that apply) A. Suggest that his parents bring in video games for him to play B. Provide a television and DVDs for the adolescent to watch C. Limit visitors to the adolescence immediate family D. Involve the adolescent and treatment decisions when possible E. Allow the adolescent to perform his own morning care
A B D E
A nurse is planning diversionary activities for preschoolers on an inpatient pediatric unit. Which of the following activities should the nurse include? (Select all that apply) A. Assembling puzzles B. Pulling wheeled toys C. Using musical toys D. Playing with puppets E. Coloring with crayons
A C D E
A nurse is preparing a health promotion course for a group of middle adults. Which of the following strategies should the nurse recommend? (Select all that apply) A. Eye examination every 1 to 3 years B. Decreased intake of calcium supplements C. Do you x-ray screening for osteoporosis D. Increase intake of carbohydrate in the diet E. Screening for depressive disorders
A C D E
A nurse is talking with an older adult client about improving her nutritional status. Which of the following interventions should the nurse recommend? (Select all that apply) A. Increase protein intake to increase muscle mass B. Decrease fluid intake to prevent urinary incontinence C. Increase calcium intake to prevent osteoporosis D. Limit sodium intake to prevent edema E. Increase fiber intake to prevent constipation
A C D E
A nurse is caring for an 82-year-old client in the emergency department who has an oral body temperature of 38.3°C (101°F), pulse rate 114/min, and respiratory rate 22/min, He is restless and his skin is warm. Which of the following intervention should the nurse take? Select all that apply A. Obtain culture specimens before initiating antimicrobials B. Restrict the clients oral fluid intake C. Encourage the client to rest and limit activity D. Allow the client to shiver to dispel excess heat E. Assist the client with oral hygiene frequently
A C E
A nurse is collecting history and physical examination data from a middle adult. The nurse should expect to find decreases in which of the following physiologic functions? (Select all that apply) A. Metabolism B. Ability to hear low-pitched sounds C. Gastric secretion D. Far vision E. Glomerular filtration
A C E
A nurse manager is reviewing guidelines for preventing injury with staff nurses. Which of the following instruction should the nurse manager include? (Select all that apply)
A. Request assistance when repositioning a client B. Avoid twisting your spine or bending at the waist D. Use smooth movements when lifting and moving clients.
A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor?
B) Grasp a skinfold on chest under clavicle, release, and note whether it's springs back.
A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse take first when using the nursing process?
B) Obtain client information
A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention?
B) Obtaining cotton balls for the tracheostomy
A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a secondary prevention.
B) Screening groups of older adults and nursing care facilities for early influencer manifestations
A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who will have emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client?
B) The client reports severe
A nurse is providing discharge instructions to a client who has a prescription for oxygen use at home. Which of the following information should the nurse include about home oxygen safety? (Select all that apply)
B. Nail polish should not be used near a client who is receiving oxygen C. A "no smoking" sign should be placed on the front door E. If I or extinguisher should be readily available in the home
A nurse educator is reviewing proper body mechanics during employee orientation. Which of the following statements shit the nurse identify as an indication that an attendee understands the teaching? (Select all that apply)
B. The lower my center of gravity the more stability I have C. To broaden my base of support I should spread my feet apart D. When I lived an object I should hold it as close to my body as possible
A nurse is caring for a patient who is 24 hr postoperative following an inguinal hernia repair. The client is tolerating clear liquids well, has active bowel sounds, and is expressing a deal for "real food. " The nurse told the client that she will call the surgeon and ask. The surgeon hears the nurse's report and prescribes a full liquid diet. the nurse used which of the following levels of critical thinking?
Basic
A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress?
C) I keep having nightmares about my upcoming surgery
A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to wheelchair. Which of the following techniques should the nurse use?
C) Place a wheelchair at 45° angle to the bed
A nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints?
C) Remove the restraints one at a time
A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2 (102.6 F), heart rate of 105/min, a soft nontender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse's priority.
C) Temperature
A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand-washing technique?
C) The nurse washes her hands held higher than her elbow
A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a providers prescription. Which of the following interventions should the charge nurse include? (Select all that apply)
C-Showing a client how to use progressive muscle relaxation. D-Performing a daily bath after the evening meal. E-Re-positioning a client every two hours to reduce pressure ulcer risk.
A nurse is preparing a client who is scheduled for a hysterectomy for transport to the operating room, when the client states she no longer wants to have the surgery. Which of the following actions should the nurse take?
D) Notify the provider about the clients decision
A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first?
D) Perform hand hygiene
A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethescope to auscultate the aortic valve?
D) Second intercostal space to the right of the sternum
A nurse is witnessing a client sign an informed consent form for surgery. Which of the following describes what the nurse is affirming by this action?
D) The signature on the pre-operative consent form is the clients
A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular size cuff for a client who is obese. Which of the following explanations should the nurse give the AP?
D) Using a cuff that is too small will result in an inaccurately high rating
A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client's dentures be removed prior to surgery. Which of the following responses should the nurse .make?
D) What worries you about being without your teeth?
A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month that might require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following statements should the nurse make to the client?
D) donate autologous blood before the surgery
A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following action should the nurse take?
D) place the bladder of the cuff over the posterior aspect of the thigh