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FUNDAMENTALS CMS MIDTERM EXAM
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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 ------CORRECT ANSWER---------------A 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 wishes about organ donation E. Introduce the client to his roommate ------CORRECT ANSWER------------- --A B D E 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. ------CORRECT ANSWER---------------A B D E 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) 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 ------CORRECT ANSWER---------------B C E 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? A. Body mass index B. Usual times for meals and snacks C. Favorite foods D. Any difficulty swallowing ------CORRECT ANSWER---------------D
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 ------CORRECT ANSWER---------------B D 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 instruments 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 ------ CORRECT ANSWER---------------B C D 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 ------CORRECT ANSWER------ ---------A B C E 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? A. Allergic reaction B. Ringworm C. Systemic lupus erythematosus D. Herpes zoster ------CORRECT ANSWER---------------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? ------CORRECT ANSWER---------------D 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 ------CORRECT ANSWER----------- ----A B
A. I will place the client on his side B. I will go to the nurses station for assistance C. I will administer his medications D. I will prepare to insert an airway ------CORRECT ANSWER---------------B A nurse observes smoke coming from under the door of the staff lounge. Which of the following actions is the nurses priority? A. Extinguish the fire B. Activate the fire alarm C. Move clients who are nearby D. Close all open doors on the unit ------CORRECT ANSWER---------------C A nurse is caring for a client who has a history of falls. Which of the following actions is the nurses priority? A. Complete a fall-risk assessment B. Educate the client and family about fall risks C. Eliminate safety hazards from the clients environment D. Make sure the client uses assistive aids in his possession ------ CORRECT ANSWER---------------A 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? 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 ------CORRECT ANSWER---------------D 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 ------ CORRECT ANSWER---------------B C E 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 ------CORRECT ANSWER---------------A 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? A. I will set my water heater at 130°F B. Once my baby can sit up he should be safe in the bathtub C. I will place my baby on his stomach to sleep
C. Semi-prone D. Trendelenburg ------CORRECT ANSWER---------------B 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? A. Obtain a walker for the client to use to transfer back to bed B. Call for additional staff to assist with the transfer C. Use a transfer belt and assist the client back into bed D. Determine the clients ability to help with the transfer ------CORRECT ANSWER---------------D 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? A. Lie on her back with her head and shoulders on a pillow B. Lie flat on her stomach with her head to one side C. Sit on the side of her bed and rest her arms over pillows on top of her bedside table D. Lie on her side with her weight on her hip and shoulder with her arm flexed in front of her ------CORRECT ANSWER---------------C 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 C. Keep your knees slightly lower than your hips when sitting for long periods of time D. Use smooth movements when lifting and moving clients
E. Take a break from repetitive movements every 2 to 3 hrs to flex and stretch her joints and muscles ------CORRECT ANSWER---------------A B D 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) A. My line of gravity should fall outside my base of support 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 E. When pulling an object, I should move my front foot forward ------ CORRECT ANSWER---------------B C D A nurse is caring for multiple clients during a mass casualty event. Which of the following clients is the priority? A. A client who received crush injuries to the chest and abdomen and is expected to die B. A client who has a 4 inch laceration to the head C. A client who has partial-thickness and full-thickness burns to his face neck and chest D. A client who has a fractured fibula and tibia ------CORRECT ANSWER--- ------------C 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) A. Open doors to client rooms
A. A client who is dehydrated and receiving IV fluids and electrolytes B. A client who has a nasogastric tube to treat a small bowel obstruction C. A client who is scheduled for elective surgery D. A client who has chronic hypertension and blood pressure 135/85 mm hemoglobin E. A client who has acute appendicitis and is scheduled for an appendectomy ------CORRECT ANSWER---------------C D 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? A. Measure vital signs B. Encourage HIV screening C. Determine risk factors D. Instruct the client to use condoms ------CORRECT ANSWER--------------- C 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 D. Devise and set goals for the client E. Teach stress management strategies ------CORRECT ANSWER----------- ----A B C E
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? A. Testicular examination B. Blood glucose C. Fecal occult blood D. Prostate-specific antigen ------CORRECT ANSWER---------------A 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 ------CORRECT ANSWER---------------D) Pericardial friction rub 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. ------ CORRECT ANSWER---------------D) place the bladder of the cuff over the posterior aspect of the thigh A charge nurse is teaching adult cardiopulmonary resusciation (CPR) to a group of newly licensed nurses.
C. The learning theory the nurse uses to teach the dietary changes. D. The extent of the dietary changes planned for the client. ------CORRECT ANSWER---------------A) The involvement of the client in planning the change 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. ------CORRECT ANSWER---------------B) Obtaining cotton balls for the tracheostomy 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. ------CORRECT ANSWER---------------C) Raise the level of the bed 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. ------ CORRECT ANSWER---------------D) The signature on the pre-operative consent form is the clients
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 ------CORRECT ANSWER---------------D) Perform hand hygiene 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? ------CORRECT ANSWER---------------D) What worries you about being without your teeth? 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. ------CORRECT ANSWER------------ ---C) I keep having nightmares about my upcoming surgery 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.
D. Ask the provider to order a blood culture to determine the risk of infection. ------CORRECT ANSWER---------------C) Carefully remove the gloves and follow with hand hygiene 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. ------CORRECT ANSWER---------------B) Absent Val sounds with distention 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." ------CORRECT ANSWER---------------A) Tell me what I can do to help you overcome your fear of giving yourself injections 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. ------CORRECT ANSWER---------------A) lock the wheels on the bed and stretcher
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. ------CORRECT ANSWER---------------C) Sit and hold the clients hand 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. ------CORRECT ANSWER---------------B) Grasp a skinfold on chest under clavicle, release, and note whether it's springs back. 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.
