CMS #37-46
a nurse is caring for a client who weighs 80kg (176lb) and is 1.6m (5'3") tall. calculate her BMI and determine whether the client's BMI indicates that she is of a healthy weight, overweight, or obese
BMI: 31.25 (>30=obese)
a client who has an indwelling catheter reports a need to urinate. which of the following actions should the nurse take? a. check to see whether the catheter is patent b. reassure the client that it is not possible for her to urinate c. recatheterize the bladder with a large-gauge needle d. collect a urine specimen for analysis
a
a nurse at a clinic is collecting data about pain from a client who reports severe ab pain. the nurse asks the client whether he has nausea and has been vomiting. which of the following pain characteristics is the nurse attempting to determine? a. presence of associated manifestations b. location of the pain c. pain quality d. aggravating and relieving factors
a
a nurse is assessing a client as part of an admission history. the client reports drinking an herbal tea every afternoon at work to relieve stress. the nurse should suspect the tea includes which of the following ingredients? a. chamomile b. ginseng c. ginger d. echinacea
a
a nurse is beginning a complete bed bath for a client. after removing the client's gown and placing a bath blanket over him, which of the following areas should the nurse wash first? a. face b. feet c. chest d. arms
a
a nurse is caring for a client scheduled for abdominal surgery. the client reports being worried. which of the following actions should the nurse take? a. offer info on a relaxation technique and ask the client if he is interested in trying it b. request a social worker see the client to discuss meditation c. attempt to use biofeedback techniques with the client d. tell the client many people feel the same way before surgery and to think of something else
a
a nurse is caring for a client who has a prescription for a 24-hr urine collection . which of the following actions should the nurse take? a discard the first voiding b. keep the urine in a single container at room temp c. ask the client to urinate and pour the urine into a specimen container d. ask the client to urinate into the toilet, stop midstream, and finish urinating into the specimen container
a
a nurse is planning care for a client who develops dyspnea and feels tired after completing her morning care. which of the following actions should the nurse include in the client's plan of care? a. schedule rest periods during monitoring care b. D/C morning care for 2 days c. perform all care as quickly as possible d. ask a family member to come in to bathe the client
a
a nurse is planning care for a client who is on bed rest. which of the following interventions should the nurse plan to implement? a. encourage the client to perform anti embolic exercises every 2 hours b. instruct the client to cough and deep breathe every 4 hours c. restrict the client's fluid intake d. reposition the client every 4 hours
a
a nurse is teaching a client how to administer medication through a jejunostomy tube. which of the following instructions should the nurse include? a. "flush the tube before and after each medication" b. "mix your medications with your enteral feeding" c. "push tablets through the tube slowly" d. "mix all the crushed medications prior to dissolving them in water"
a
a nurse is caring for a client who has several risk factors for hearing loss. which of the following medications, that the client currently takes, should alert the nurse to a further risk for ototoxicity? (SATA) a. furosemide b. ibuprofen c. cimetidine d. simvastatin e. amiodarone
a b
a nurse in a senior center is counseling a group of older adults about their nutritional needs and considerations. which of the following info should the nurse include ? (SATA) a. older adults are more prone to dehydration than younger adults are b older adults need the same amount of most vitamins and minerals as younger adults do c. many older men and women need calcium supplementation d. older adults need more calories than they did when they were younger e. older adults should consume a diet low in carbohydrates
a b c
a nurse is preparing to administer a cleaning enema to an adult client in preparation for a diagnostic procedure. which of the following should the nurse take ? (SATA) a. warm the enema solution prior to installation b. position the clients on the left side with the right leg relaxed forward c. lubricate the rectal tube of the nozzle d. slowly insert the rectal thermometer
a b c
a nurse is instructing a client, who has an injury of the left lower extremity, about the use of a cane. which of the following instructions should the nurse include? (SATA) a. hold the cane on the right side b. keep two points of support on the floor c. place the cane 38cm (15in) in front of the feet before advancing d. after advancing the cane, move the weaker leg forward e. advance the stronger leg so that it aligns evenly with the cane
a b d
a nurse is talking with a client about ways to help him sleep and rest. which of the following recommendations should the nurse give to the client to promote e sleep and rest? (SATA) a. practice muscle relaxation techniques b. exercise each morning c. take an afternoon nap d. alter the sleep environment for comfort e. limit fluid intake at least 2 hr before bedtime
a b d e
a nurse in a provider's office is caring for a client who states that, for the past week, she has felt tired during the day and cannot sleep at night. which of the following responses should the nurse ask when collecting data about the client's difficulty sleeping? (SATA) a. "does your lack of sleep interfere with your ability to function during the day?" b. ''do you feel confused in the late afternoon?'' c. "do you drink coffee, tea, or other caffeinated drinks? if so, how many cups per day?" d. "has anyone ever told you that you seem to stop breathing for a few seconds while you sleep?" e. "tell me about any personal stress you are experiencing"
a c d e
a nurse is preparing a presentation at a local community center about sleep hygiene. when explaining REM sleep, which of the following characteristics should the nurse include? (SATA) a. REM sleep provides cognitive restoration b. REM sleep lasts about 90 min c. it is difficult to awaken a person in REM sleep d. sleepwalking occurs during REM sleep e. vivid dreams are common in REM sleep
a c e
a nurse is reviewing complementary and alternative therapies with a group of nursing students. the nurse should classify which of the following interventions as a mind-body therapy? (SATA) a. art therapy b. acupressure c. yoga d therapeutic touch e. biofeedback
a c e
a nurse is caring for a client who reports difficulty hearing. which of the following assessment findings indicate a sensorineural hearing loss in the left ear? (SATA) a. weber test showing lateralization to the right ear b. light reflex at 10 o'clock in the left ear c. indications of obstruction in the left ear canal d. rinne test showing less time for air and bone conduction e. rinne test showing air conduction less than bone conduction in the left ear
a d
a nurse is instructing a client who has DM about foot care. which of the following guidelines should the nurse include? (SATA) a. inspect the feet daily b. use moisturizing lotion on the feet c. wash the feet with warm water and let them air dry d. use OTC products to treat abrasions e. wear cotton socks
a, b e
a nurse is performing mouth care for a client who is unconscious. which of the following actions should the nurse take? a. turn the client's head to the side b. place two fingers in the client's mouth to open c. brush the client's teeth once per day d. inject a mouth rinse into the center of the client's mouth
a.
a nurse is caring for a client who is at high risk for aspiration. which of the following actions should the nurse take? a. give the client thin liquids b. instruct the client to tuck her chin when swallowing c. have the client use a straw d. encourage the client to lie down and rest after meals
b
a nurse is evaluating teaching on a client who has a new Rx for a sequential compression device. which of the following client statements should indicate to the nurse the client understands the teaching? a. "this device will keep me from getting sores on my skin" b. "this thing will keep the blood pumping through my leg" c. "with this thing on, my leg muscles won't get weak" d. "this device is going to keep my joints in good shape"
b
a nurse is instructing a client who has a new Dx of narcolepsy about measures that might help with self-management. which of the following statements should the nurse identify as an indication that the client understands the instructions? a. "I'll add plenty of carbs to my meals" b. "i'll take a short nap whenever I feel a little sleepy" c "i'll make sure I stay warm when I am at my desk at work" d. "it's ok to drink alcohol as long as I limit it to one drink per day"
b
a nurse is planning to use healing intention with a client who is recovering from a lengthy illness. which of the following is the priority action the nurse should take before attempting this particular mind-body intervention? a. tell the client the goal of the therapy is to promote healing b. ask whether the client is comfortable with using prayer c. encourage the client participate actively for best results d. instruct the client to relax during the therapy
b
a nurse is preparing to inject heparin SC for a client who is post-op. which of the following actions should the nurse take? a. use a 22-gauge needle b. select a site on the client's abdomen c. spread the skin with the thumb and index finger d. observe for bleb formation to confirm proper placement
b
a nurse is preparing to perform denture care for a client. which of the following actions should the nurse plan to take? a. pull down and out at the back of the upper denture to remove b. brush the dentures with a toothbrush and denture cleaner c. rinse the dentures with hot water after cleaning them d. place the dentures in a clean, dry storage container after cleaning them
b
a nurse is taking with a client who reports constipation. when the nurse discusses dietary changes that can help prevent constipation, which of the following foods should the nurse recommend? a. macaroni and cheese b. fresh fruit and whole wheat toast c. bread pudding and yogurt d. roast chicken and white rice
b
a nurse is teaching an adult client how to administer ear drops. which of the following statements should the nurse identify as an indication that the client understands the proper techniques? a. "I will straighten my ear canal by pulling my ear down and back" b. "I will gently apply pressure with my finger to the front part of my ear after putting in the drops" c. "i will insert the nozzle of the ear drop bottle snug into my ear before squeezing the drops in " d. "after the drops are in, I will place a cotton ball all the way into my ear canal"
b
a nurse is caring for a client who has had diarrhea for 4 days. when assessing the client, the nurse should expect which of the following findings? (SATA) a. bradycardia b. hypotension c. elevated temp d. poor skin turgor e. peripheral edema
b c d
a nurse is preparing to indicate a bladder-retraining program for a client who has incontinence. which of the following actions should the nurse take? (SATA) a. establish a schedule of urinating prior to meal times b. have the client record urination times c. gradually increase the urination intervals d. remind the client to hold urine until the next scheduled urination time e. provide a sterile container for urine
b c d
a nurse in a provider's office is evaluating a client who reports losing control of urine whenever she coughs, laughs or sneezes. the client relates a history of 3 vaginal births, but no serious accidents or illnesses. which of the following interventions should the nurse suggest for helping to control or eliminate the client's incontinence? (SATA) a. limit total daily fluid intake b. decrease or avoid caffeine c. take calcium supplements d. avoid drinking alcohol e. use the Crecle measure
b d
a nurse is caring for a client who recently had a CVA and has aphasia. which of the following interventions should the nurse use to promote communication with this client? (SATA) a. increase the volume of your voice b. make sure only one person speaks at a time c. avoid discouraging the client by saying that you don't understand him d. allow plenty of time for the client to respond e. use brief sentences with simple words
b d e
a nurse is caring for a client who is postoperative. which of the following interventions should the nurse take to reduce the risk of thrombus development? (SATA) a. instruct the client not to perform the Valsava maneuver b. apply elastic stockings c. review lab values for total protein level d. place pillows under the client's knees and lower extremities e. assist the client to change position often
b e
a nurse is caring for a client who had an amphetamine overdose and has sensory overload. which of the following interventions should the nurse implement? a. immediately complete a thorough assessment b. put the client in a room with a client who has hearing loss c .provide a private room, and limit stimulation d. speak at a higher volume to the client and encourage ambulation
c
a nurse is caring for a client who has been sitting in a chair for 1 hr. which of the following complications is the greatest risk to the client? a. decreased subcutaneous fat b. muscle atrophy c. pressure ulcer d. fecal impaction
c
a nurse is caring for a client who is 1 day post-op following a TKA. the client states his pain level is 10 on a scale of 0 to 10. after reviewing the client's MAR, which of the following medications should the nurse administer? a. meperidine 75 mg IM b. fentanyl 50 mcg/hr transdermal patch c. morphine 2mg IV d. oxycodone 10 mg PO
c
a nurse is caring for a client who is receiving morphine via a patient-controlled analgesia (PCA) infusion device after abdominal surgery. which of the following statements indicates that the client knows how to use this device? a. "i'll wait to use the device until it's absolutely necessary" b. "i'll be careful about pushing the button too much so I won't get an overdose" c. "i should tell the nurse if the pain doesn't stop while I am using the device" d. "i will ask my adult child to push the dose button when I am sleeping"
c
a nurse is caring for a client who requires a low-residue diet. the nurse should expect to see which of the following foods on the client's meal tray? a. cooked barley b. pureed broccoli c. vanilla custard d. lentil soup
c
a nurse is caring for an older adult client who has been following the facility's routine and bathing in the morning. however, at home, she always takes a warm bath just before bedtime. now she is having difficulty sleeping at night. which of the following actions should the nurse take first? a. rub the client's back for 15 min before bedtime b. offer the client warm milk and crackers at 2100 c. allow the client to take a bath in the evening d. ask the provider for a sleep medication
c
a nurse is collecting data from a client who is reporting pain despite taking analgesia. which of the following actions should the nurse take to determine the intensity of the client's pain? a. ask the client what precipitates the pain b. question the client about the location of the pain c. offer the client a pain scale to measure his pain d. use open-ended questions to identify the client's pain sensations
c
a nurse is teaching a group of nursing students on complementary and alternatives they can incorporate into their practice without the need for specialized licensing or certification. which of the following should the nurse encourage the students to use? (SATA) a. guided imagery b. massage therapy c. meditation d. music therapy e. therapeutic touch
c d
a nurse is monitoring a client who is receiving opioid analgesia for adverse effects of the medication. which of the following effects should the nurse anticipate? (SATA) a. urinary incontinence b diarrhea c. bradypnea d. orthostatic hypotension e. nausea
c d e
a nurse is caring for a client who will perform fecal occult blood testing at home. which of the following info should the nurse include when explaining the procedure to the client ? a. eating more protein is optimal prior to testing b. one stool specimen is sufficient for testing c. a red color change indicates a positive test d. the specimen cannot be contaminated with urine
d
a nurse is discussing the care of a group of clients with a newly licensed nurse. which of the following clients should the newly licensed nurse identify as experiencing chronic pain? a. a client who has a broken femur and reports hip pain b. a client who has incisional pain 72 hr following pacemaker insertion c. a client who has food poisoning and reports abdominal cramping d. a client who has episodic back pain following a fall 2 years ago
d
a nurse is preparing a presentation about basic nutrients for a group of high school athletes. she should explain that which of the following nutrients provides the body with the most energy? a. fat b. protein c. glycogen d. carbohydrates
d
a nurse is reviewing instructions with a client who has a hearing loss and has just started wearing hearing aids. which of the following statements should the nurse identify as an indication that the client understands the instructions? a. "i use a damp cloth to clean the outside part of my hearing aids" b. "i clean the ear molds of my hearing aids with rubbing alcohol" c. "i keep the volume of my hearing aids turned up so i can hear better" d. "i take the batteries out of my hearing aids when i take them off at night"
d
a nurse is teaching a client about taking multiple oral medications at home to include time-release capsules, liquid medications, enteric-coated pills, and opioids. which of the following statements should the nurse identify as an indication that the client understands the instructions? a. "i can open the capsule with the beads in it and sprinkle them on my oatmeal" b. "if i am having a difficulty swallowing, I will add the liquid medication to a batch of pudding" c. "i can crush the pills with the coating on them" d. "i will eat two crackers with the pain pills"
d
while a nurse is administering a cleansing edema, the client reports abdominal cramping. which of the following actions should the nurse take? a. have the client hold his breath briefly and bear down b. D/C the fluid instillation c. remind the client that cramping is common at this time e. lower the enema fluid container
d
a nurse is reviewing factors that increase the risk of UTIs with a client who has recurrent UTIs. which of the following factors should the nurse include? (SATA) a. frequent sexual intercourse b. lowering of testosterone levels c. wiping from front to back d. location of the urethra in relation to the anus e. frequent catheterization
d e