Fundamentals CMS Midterm
A nurse is caring for a client who has a history of falls. Which of the following actions is the nurse's priority? A. Complete a fall-risk assessment B. Educate the client and family about fall risks C. Eliminate safety hazards from the client's environment D. Make sure the client uses assistive aids in his possession
Complete a fall-risk assessment
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? A. Call for assisstance B. Begin Chest compressions C. Confirm unresponsiveness. D. Give rescue breaths.
Confirm unresponsiveness
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. A client who has terminal cancer requests hospice care in her home B. A client asks about community resources available for older adults C. A client states that she wants her child baptized before surgery D. A client requests an electric wheelchair for use after discharge E. A client states that he does not understand how to use a nebulizer
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. A nurse on a medical surgical unit demonstrate signs of chemical impairment. B. A nurse overhears another nurse telling an older adult client that if he doesn't stay in bed, she will have to apply restraints. C. A family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill D. A client who is terminally ill hesitates to name her spouse on her durable power of attorney form.
A family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill
A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take? A. Encourage the child to cough frequently to clear congestion from anesthesia. B. Place a heating pad at the child's neck for comfort. C. Administer analgesics to the child on a routine schedule throughout the day and night. D. Provide the child with ice cream when oral intake is initiated.
Administer analgesics to the child on a routine schedule throughout the day and night
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? A. Assault B. Battery C. False imprisonment D. Invasion of privacy
Assault
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? A. Basic B. Commitment C. Complex D. Integrity
Basic
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) A. Bathing B. Ambulating C. Toileting D. Determining pain level E. Measuring vital signs
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? A. Fidelity B. Autonomy C. Justice D. Beneficence
Beneficence
A nurse is preparing information for a change of shift report; which of the following information should the nurse include in the report? A. Input and output for the shift B. Blood pressure from the previous day C. Bone scan scheduled for today D. Medication routine from the medication administration record
Bone scan scheduled for today
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? A. Carbon monoxide has a distinct odor B. Water heaters should be inspected every five years C. The lungs are damaged from carbon monoxide inhalation D. Carbon monoxide binds with hemoglobin in the body
Carbon monoxide binds with hemoglobin in the body
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? A. Wash the gloved hands and then throw the gloves away. B. Prepare an incident report to document the event. C. Carfefully remove the gloves and follow with hand hygiene. D. Ask the provider to order a blood culture to determine the risk of infection.
Carefully remove the gloves and follow with hand hygiene
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? A. Collaborating with providers to perform obesity screenings during routine office visits B. Ensuring the availability of specialized beds in rehabilitation centers for clients who have obesity C. Providing specialized intraoperative training regarding surgical treatments for obesity D. Educating acute care nurses on post operative complications related to obesity
Collaborating with providers to perform obesity screenings during routine office visits
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? A. Measure the pulse using a Doppler ultrasound stethoscope. B. Check the client's pedal pulses. C. Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart. D. Take the pulse at each peripheral site and count the rate for 30 seconds.
Count the apical pulse rate for one full minute and describe the written in the chart
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? A. Confidence B. Perseverance C. Integrity D. Discipline
Discipline
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? A. Turn on the machine every 15 min to measure the client's blood pressure. B. Record only blood pressure readings needed for the 15-min intervals. C. Obtain manural and automatic readings and compare them/. D. Disconnect the machine, and measure the blood pressure manually every 15 min.
Disconnect the machine, and measure the blood pressure manually every 15 min
Place in order: Inspection Palpation Percussion Auscultation
Inspection, Auscultation, Palpation, Percussion
A nurse is caring for a client who is postoperative and has parlytic ileus. Which of the following abdominal assessments should the nurse expect? A. Frequent bowel sounds with flatus. B. Absent bowel sounds with distention C. Hyperactive bowel sounds with diarrhea. D. Normal bowel sounds with increased peristalsis.
Absent Val sounds with distention
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 nurse's station? A. A middle adult who is postoperative following a laparoscopic cholecystectomy B. A middle adult who requires telemetry for a possible myocardial infarction C. Young adult who is postoperative following an open reduction internal fixation of the ankle D. An older adult who is postoperative following a below the knee amputation
An older adult who is postoperative following a below the knee amputation
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 client's family? A. Body mass index B. Usual times for meals and snacks C. Favorite foods D. Any difficulty swallowing
Any difficulty swallowing
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 B. Plan of care C. Nursing interventions performed. D. Evaulation of progress.
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 client's self motivation B. Keep detailed records of each client's progress. C. Test client learning after each teaching session. D. Avoid discussing areas that might cause client anxiety.
Attempt to increase the client's self-motivation
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 client's choice is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence
Autonomy
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? A. Change the topic because the client is trying to divert attention from the illness to the nurse. B. Encourage the client to express his thoughts about death and dying. C. Tell the client that religious beliefs are a personal matter. D. Offer to contact the client's minister or the facility's chaplain.
Encourage the client to express his thoughts about death and dying
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 C. Assess how the client tolerates the transfer D. Give a verbal transfer report via telephone E. Complete a transfer form for the receiving facility.
Ensure that the client has possession of his valuables Confirm that the rehabilitation center has a room available at the time of transfer Give a verbal transfer report via telephone Complete a transfer form for the receiving facility.
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? A. Monitoring evidence-based practice for clients who have a specific diagnosis B. Ensuring that healthcare providers comply with regulations C. Setting quality standards for accreditation of healthcare facilities D. Determining if medications are safe for administration to clients
Ensuring the healthcare providers comply with regulations
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 C. Inform the client that advanced directives are required for hospital admission D. Document the clients wish about organ donation E. Introduce the client to his roommate
Explain the roles of other care delivery staff Begin discharge planning Document the clients wish about organ donation Introduce the client to his roommate
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? A. Assault B. False imprisonment C. Negligence D. Breach of confidentiality
False imprisonment
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) A. A single electronic records password is provided for nurses on the same unit B. Family members should provide a code prior to receiving client health information C. Communication of client information can occur at the nurses station. D. A client can request a copy of her medical record E. A nurse my photo copy a clients medical record for transferred to another facility
Family members should provide a code prior to receiving client health information Communication of client information can occur at the nurse's station. A client can request a copy of her medical record A nurse may photocopy a client's medical record for transferred to another facility
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 C. Edema D. Pain or tenderness E. Increase in pulse and respiratory rate
Fever Malaise Increase in pulse and respiratory rate
A nurse is preparing the discharge summary for a client who has had a knee 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) A. Advance directive status B. Follow-up care C. Instructions for diet and medications D. Most recent vital sign data E. Contact information for the home healthcare agency
Follow-up care Instructions for diet and medications Contact information for the home healthcare agency
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? A. Push on a fingernail bed until it blanches, release it, and observe how long it takes the skin to become pink. B. Grasp a skinfold on chest under clavicle, release, and note whether is springs back. C. Press the skin in above the ankle for 5 seconds, release it, and note the depth of the impression. D. Measure the skin fold thickness at the upper arm using a pair of calbrated skinfold calipers.
Grasp a skinfold on chest under clavicle, release, and note whether it's springs back.
A nurse is caring for a client who presents with linear clusters of fluid-containing vesicles with some crusting. The nurse should identify the client has manifestations of which of the following conditions? A. Allergic reaction B. Ringworm C. Systemic lupus erythematosus D. Herpes zoster
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). A. Home health care B. Rehabilitation facilities C. Diagnostic centers D. Skilled nursing facilities E. Oncology centers
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? A. Hypotension B. Bradycardia C. Clammy skin D. Bradypnea
Hypotension
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? A. My parents are retired, and they have come to help out with our children. B. I am going to ask my husband to go to counseling with me. C. I keep having nightmares about my upcoming surgery. D. My girlfriends bought me a nice wig.
I keep having nightmares about my upcoming surgery
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? A. I'd rather have my brother make decisions for me, but I know it has to be my wife. B. I know they won't go ahead with the surgery unless I prepare these forms. C. I plan to write that I don't want them to keep me on a breathing machine. D. I will get my regular doctor to approve my plan before I hand it in at the hospital.
I plan to write that I don't want them to keep me on a breathing machine.
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." B. "Urinary incontinence is something I will have to live with as I grow older." C. "I can expect to have less ear wax as I get older." D. "My stomach will empty more quickly after meals as I grow older."
I should expect my heart rate to take longer to return to normal after exercise as I get older
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? A. I will determine the most important client problems that we should address B. I will review the past medical history on the clients record to get more information C. I will go carry out the new prescriptions from the provider D. I will ask the client if his nausea has resolved
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? A. I will place the client on his side B. I will go to the nurse's station for assistance C. I will administer his medications D. I will prepare to insert an airway
I will go to the nurse's station for assistance
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? A. Explain the x-ray procedure to the client. B. Help the client into a wheelchair before the transporter arrives. C. Ask if the client has any questions. D. Identify the client using two identifiers.
Identify the client using to identifiers
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) A. Intensive care unit B. Oncology treatment center C. Burn center D. Cardiac rehabilitation E. Home healthcare
Intensive care unit 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? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence
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? A. Knowledge B. Experience C. Intuition D. Competence
Knowledge
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) A. Place a belt restraint on the client when he is sitting on the bedside commode B. Keep the bed in its lowest position with side rails up C. Make sure that the clients call light is within reach D. Provide the client with nonskid footwear E. Complete a fall-risk assessment
Make sure that the clients call light is within reach Provide the client with nonskid footwear Complete a fall-risk assessment
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) A. Make sure the surgeon obtained the client's consent B. Witness the client signature on the consent form C. Explain the risks and benefits of the procedure D. Describe the consequences of choosing not to have the surgery E. Tell the client about alternatives to having the surgery
Make sure the surgeon obtained the client's 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). A. Preferred provider organization (PPO) B. Medicare C. Long term care insurance D. Exclusive provider organization (EPO) E. Medicaid
Medicare Medicaid
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 C. Conflict with provider and nursing staff D. Omission of prescription E. Missed specimen collection of a prescribe laboratory test
Medication error Needle sticks Omission of prescription
A nurse observes smoke coming from under the door of the staff lounge. Which of the following actions is the nurse's priority? A. Extinguish the fire B. Activate the fire alarm C. Move clients who are nearby D. Close all open doors on the unit
Move clients who are nearby
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) A. Right client B. Right supervision and evaluation C. Right direction and communication D. Right time E. Right circumstances
Right supervision and evaluation Right direction and communication Right circumstances
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) A. Family members who smoke must be at least 10 feet from the client when oxygen is in use 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 D. Cotton bedding and clothing should be replaced with items made of wool E. If I or extinguisher should be readily available in the home
Nail polish should not be used near a client who is receiving oxygen A "no smoking" sign should be placed on the front door If I or extinguisher should be readily available in the home
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? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence
Nonmaleficence
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? A. Tell the client it is too late for her to change her mind because the surgery is already scheduled. B. Telephone the operating room and cancel the surgery. C. Inform the client's family about the situation. D. Notify the provider about the client's decision.
Notify the provider about the client's decision
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? A. Identify goals for client care. B. Obtain client information. C. Document nursing care needs. D. Evaluate the effectivness of nurse care.
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? A. Obtaining hydrogen peroxide for the trachesotomy care. B. Obtainging cotton balls for the tracheostomy care. C. Obtaining sterile gloves for the tracheostomy care. D. Obtaining a sterile brush for the tracheostomy care.
Obtaining cotton balls for the tracheostomy
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? A. Social worker B. Certified nursing assistant C. Registered dietitian D. Occupational therapist
Occupational therapist
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? A. Orient a client to his room B. Conduct a client care conference C. Review medical prescriptions D. Develop a plan of care
Orient a client to his room
A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first? A. Open all sterile supplies and solutions. B. Stabilize the tracheostomy tube. C. Don sterile gloves D. Perform hand hygiene
Perform hand hygiene
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? A. Audible Click B. Murmur C. Third heart sound D. Pericardial friction rub
Pericardial friction rub
When entering a client's 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? A. Keep the sterile field at least 6 feet away from the client's bedside. B. Instruct the client to refrain from coughing and sneezing during the dressing change C. Place a mask on the client to limit the spread of micro-organisms into the surgical wound D. Keep a box of facial tissues nearby for the client to use during the dressing change
Place a mask on the client to limit the spread of micro-organisms into the surgical wound
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? A. Stand toward the client's stronger side. B. Instruct the client to lean backward from the hips. C. Place the wheelchair at a 45degree angle to the bed. D. Assume a narrow stance with feet 15 cm (6in) apart.
Place a wheelchair at 45° angle to the bed
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 D. Identifying endemic disease E. Monitoring for common-source outbreaks
Planning and evaluating control and prevention strategies Determining public health priorities Ensuring proper medical treatment Monitoring for common-source outbreaks
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) A. Provider B. Certified nursing assistant C. Pharmacist D. Registered nurse E. Respiratory therapist
Provider Registered nurse Respiratory therapist
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 client's record? (Select all that apply) A. Cover errors with correction fluid and write in the correct information B. Put the date and time on all entries C. Document objective data leaving out opinions D. Use as many abbreviations as possible E. Wait until the end of the shift to document
Put the date and time on all entries Document objective data leaving out opinions
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? A. Charge nurse B. RN C. Practical nurse (PN) D. Assistive personnel (AP)
RN
A nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take? A. Place the client supine. B. Keep both side rails up. C. Raise the level of the bed. D. Inspect the client's mouth using a finger sweep.
Raise the level of the bed
A nurse on a medical surgical unit has received change of shift report and will care for four clients. Which of the following client's needs should the nurse assigned to an AP? A. Updating the plan of care for a client who is post operative B. Reinforcing teaching with a client who is learning to walk using a quad C. Reapplying a condom catheter for a client who has urinary incontinence D. Applying a sterile dressing to a pressure ulcer
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? A. Reassess the client to determine the reasons for an adequate pain relief B. Wait to see whether the pain lessons during the next 24 hours C. Change the plan of care to provide different pain relief interventions D. Teach the client about the plan of care for managing his pain.
Reassess the client to determine the reasons for an adequate pain relief
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? A. Tie the restraints to the side rails. B. Perform range-of-motion exercises to the wrists every 3 hrs. C. Remove the restraints one at a time. D. Obtain a PRN prescription for the restraints.
Remove the restraints one at a time
A nurse is receiving a provider's 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 D. Decline the verbal prescription because it is not an emergency situation E. Tell the charge nurse that the provider has prescribed morphine by telephone.
Repeat the details of the prescription back to the provider Have another nurse listen to the telephone prescription Obtain providers signature on the prescription within 24 hours
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? A. Alert the ANA B. Fill out an incident report C. Report the observations to the nurse manager on the unit D. Leave the nurse alone to sleep
Report the observations to the nurse manager on the unit
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. B. The clients partner states, "he said he hurts after walking about 10 minutes." C. Pain rating is three on a scale of 0 to 10 D. Skin is pink, warm, and dry E. The AP reports the client walked with a limp
Respiratory rate is 22/min with even, unlabored respirations Skin is pink, warm, and dry The AP reports the client walked with a limp
A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a secondary prevention. A. Holding a community clinic to adminster influenza immunizations. B. Screening groups of older adults in nursing care facilites for early influenza manifestations. C. Educating parents of young children about dangers of influenza. D. Finding rehabilitation programs for older adults who have complications from influenza.
Screening groups of older adults and nursing care facilities for early influencer manifestations
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? A. Fifth intercostal space just medical to the midclavicular line B. Second intercostal space to the left of the sternum C. Fifth intercostal space to the left of the sternum D. Second intercostal space to the right of the sternum.
Second intercostal space to the right of the sternum
A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider's prescription. Which of the following interventions should the charge nurse include? (Select all that apply) A. Writing a prescription for morphine sulfate as needed for pain B. Inserting a nasogastric (NG tube) to relieve gastric distention 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.
Showing a client how to use progressive muscle relaxation Performing a daily bath after the evening meal Re-positioning a client every two hours to reduce pressure ulcer risk.
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? A. Contact the family and ask them to stay with the client. B. Offer to call client's minister. C. Sit and hold the client's hand. D. Leave the room and allow the client to cry privately.
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. A. "Drink a min. of 1,000 mL of fluid daily." B. "Increase your intake of refined-fiber foods" C. "Sit on the toilet 30 min after eating a meal. D. "Take a laxative every day to maintain regularity."
Sit on the toilet 30 minutes after eating a meal
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? A. Social worker B. Certified nursing assistant C. Occupational therapist D. Speech-language pathologist
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? A. Assisting a client who is 24 hour post operative to use an incentive spirometer B. Collecting a clean catch urine specimen from a client who has a wound infection C. Providing nasopharyngeal suctioning for a client who has pneumonia D. Teaching a client who has asthma to use a metered dose inhaler
Teaching a client who has asthma to use a metered dose inhaler
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." B. "I am sure your provider will not be pleased that you refuse to give yourself insulin injections." C. "It's okay. I am sure your partner will be able to learn how to give you the insulin injections." D. "You won't be able to go home unless you learn to give yourself insulin injections."
Tell me what I can do to help you overcome your fear of giving yourself injections
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. A. Heart rate 105/min B. soft, nontender abdomen C. temperature D. overdue menses
Temperature
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? A. Rectal B. Tympanic C. Oral D. Temporal
Temporal
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) A. The roommate ambulates independently 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 minutes ago E. The client is allergic to codeine F. The client 850% of his breakfast this morning
The client ambulates with his slippers on over his Anti embolic stockings. The client uses a front-wheeled walker when ambulating The client had pain medication 30 minutes 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) A. The client seems easily agitated B. The client is non-adherent with coughing, deep breathing, and dangling C. The client may have pain medication every 4 to 6 hrs. but accepts it every 6 to 7 hrs. D. The client reports tenderness in his right lower leg E. The client's vital signs are heart rate 124/min, respiratory rate 22/min, temperature 37°C (98°F), and blood pressure 156/80 mm Hg
The client is non-adherent with coughing, deep breathing, and dangling The client may have pain medication every 4 to 6 hrs. but accepts it every 6 to 7 hrs. The client's 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 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? A. The client asks the nurse to repeat the instructions before attempting the exercise. B. The client reports severe pain. C. The client asks the nurse how often deep breathing should be done after surgery. D. The client tells the nurse that this exercise will probably be painful after surgery.
The client reports severe
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? A. The flap closest to the body B. The right side flap C. The left side flap D. The flap farthest from the body
The flap farthest from the body
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) A. A bottle containing a sterile solution B. The edge of the sterile drape at the base of the field 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
The inner wrapping of an item on the sterile field An irrigation syringe on the sterile field One gloved hand with the other gloved hand
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. B. The emphasis the provider places on the dietary changes. C. The learning theory the nurse uses to teach the dietary changes. D. The extent of the dietary changes planned for the client.
The involvement of the client in planning the change
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) A. The provider drops a sterile instrument onto the near side of the sterile field 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 E. The clients hand brushes against the outer edge of the sterile field
The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field The procedure is delayed one hour because the provider receives an emergency call The nurse turns to speak to someone who enters through the door behind the nurse
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? A. The nurse washes each part of her hands with 5 strokes. B. The nurse washes from the elbows down to the hands. C. the nurse washes with her hands held higher then her elbows. D. The nurse uses minimal friction when washing her hands.
The nurse washes her hands held higher than her elbow
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? A. The client fully understands the provider's explannation of the procedure. B. The client has been informed about the risks and benefits of the procedure. C. The nurse witnessed the provider's explanantion of the procedure. D. The signature on the preoperative consent form is the client's.
The signature on the pre-operative consent form is the clients
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." B. "I will use cold water when I wash my hands to protect my skin from becoming too dry." C. "I will apply friction for at least 10 seconds while washing my hands." D. "After washing my hands I will dry them from the elbows down."
There are times I should use soap and water rather than an alcohol-based hand rub to clean my hands
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? A. "The reading will be inaudible if the cuff is too small for the client." B. "The width of the cuff bladder should be 75% of the circumference of the client's arm." C. As long as the cuff will circle the arm the reading will be accurate. D. "Using a cuff that is too small will result in an inaccurately high reading."
Using a cuff that is too small will result in an inaccurately high rating
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) A. Apply 3 to 5 mL of liquid soap to dry hands B. Wash hands with soap and water for at least 15 seconds C. Rinse the hands with hot water D. Use a clean paper towel to turn off hand faucets E. Allow the hands to air dry after
Wash hands with soap and water for at least 15 seconds Use a clean paper towel to turn off hand faucets
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) A. Place client in a room that has negative air pressure of at least six exchanges per hour 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 D. Use sterile gloves when handling soiled linens E. Wear a gown when performing care that might result in contamination from secretions
Wear a mask when providing care within 3 ft of client Place a surgical mask on the client if transportation to another department is unavoidable Wear a gown when performing care that might result in contamination from secretions
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? A.It's for your safety. Dentures can slip and block your airway during surgery. B. You wouldn't want your teeth to be lost or broken during surgery, would you? C. The anesthesiologist requires everyone to remove their dentures. D. What worries you about being without your teeth?
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? A. "Ask your provider to prescribe epoetin before the surgery." B. "You should ask your provider about taking iron supplements prior to the surgery." C. Request a family member to donate blood for you." D. "Donate autologous blood before the surgery.
donate autologous blood before the surgery
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. B. Obtain a medical history. C. Measure vital signs. D. Assess for leg pain.
evaluate pedal pulses
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. B. Instruct the client to raise his arms above his head. C. Elevate the stretcher 2.5cm (1in) above the height of the bed. D. Log roll the client.
lock the wheels on the bed and stretcher
A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following action should the nurse take? A. Auscultate for the blood presure at the dorsalis pedis artery. B. Measure the blood pressure with the client sitting on the side of the bed. C. Place the cuff 7.6cm (3in) above the popliteal artery. D. Place the bladder of the cuff over the posterior aspect of the thigh.
place the bladder of the cuff over the posterior aspect of the thigh
