CMS Funds A

Question 1

a nurse is collecting date on four client. Which of the following findings should the nurse report to the provider?

-Heart rate 62/min
-Urine output of 200 mL over 8 hr
-Pulse oximetry 95% on room air
-BP 112/76 mm Hg

Answer 1

Urine output of 200 mL over 8 hr

Question 2

a nurse is using maslow hierarchy of needs in assisting with discharge planning for a client. Which of the following activities should the nurse recommend as the priority for this client?

-Volunteer at the local food pantry.
-Attend an exercise program.
-Find an enjoyable hobby.
-
Support environmental conservation.

Answer 2

-Attend an exercise program.

Question 3

a nurse is reinforcing teaching about carbs counting with a client who has a new diagnosis of DM. Which of the following actions should the nurse take first?

-Use pictures of different food groups to help the client plan a daily menu.
-Ask the client what they already know about meal planning.
-Give the client a brochure with sample menus for all meals.
-Involve the family in the discussion of the client’s meal plan.

Answer 3

-Ask the client what they already know about meal planning.

Question 4

a nurse is planning to administer medication to a client who has a c.diff infection. Which of the following actions should the nurse plan to take to prevent the transmission of this infection to others?

-Clean hands with an alcohol-based hand rub immediately after removing gloves.
-Remove the cover gown in the client’s room after providing care.
-Place the client in a room with negative-pressure airflow.
-Wear a mask when administering oral medications to the client.

Answer 4

-Remove the cover gown in the client’s room after providing care.

Question 4

a nurse is assisting with the admission of a client to has active TB. Which of the following actions should the nurse plan to take?

-Restrict the client’s visitors to the immediate family.
-Assign the client to a negative-pressure airflow room.
-Discard personal protective equipment outside the client’s room.
-Have the client wear a HEPA mask during transportation throughout the facility.

Answer 4

-Assign the client to a negative-pressure airflow room.

Question 5

a nurse is preparing to administer oxygen to a client who has heart failure and is having severe difficulty breathing. Whcih of the following oxygen delivery equipment should the nurse select to provide the highest concentration to the client?

-Nasal cannula
-Simple face mask
-Venturi mask
-Nonrebreather mask

Answer 5

-Nonrebreather mask

Question 6

a nurse is caring for a client who has dysphagia following a stroke. Which of the following interventions should the nurse use when feeding the client?

-Offer the client a straw to drink liquids.
-Place food toward the back of the client’s mouth.
-Encourage the client to lie down and rest for 30 min after meals.
-Instruct the client to tilt their head forward while eating

Answer 6

-Instruct the client to tilt their head forward while eating

Question 6

a nurse is caring for a client who has dyspena cause by respiratory infection. The nurse should assist the client into which of the following positions?

-Orthopneic
-Dorsal recumbent
-Sims’
-Prone

Answer 6

-Orthopneic

The nurse should assist the client into the orthopneic position by having the client sit upright either in bed or in a chair and lean forward. This position allows maximal chest expansion and facilitates breathing.

Question 7

a nurse is caring for a client who is scheduled for surgery the following day. During the night, the client is unable to sleep and is restless. Which of the following statements should the nurse make?

-“It must be difficult facing this type of surgery.”
-“Other clients who have had this surgery have done just fine.”
-“This facility is known for providing excellent care for people who need this type of surgery.”
-“I can request a sleeping pill, if you think that will help.

Answer 7

-“It must be difficult facing this type of surgery.”

Question 8

a nurse is reinforcing teaching with a client who speaks different language than the nurse. Which of the following actions should the nurse take?

-Avoid using gestures when communicating with the client.
-Communicate with the client using a translation dictionary.
-Speak loudly when communicating with the client.
-Use printed materials written in the client’s language.

Answer 8

-Use printed materials written in the client’s language.

Question 9

a nurse is collecting data from a client following a lumbar puncture. The nurse should identify which of the following findings as a potential adverse effects of this procedure?

-Fluid overload
-Diarrhea
-Headache
-Difficulty voiding

Answer 9

-Headache

Question 10

a nurse is caring for a client who reports itching 30min after receiving a newly prescribed medication. Which of the following data should the nurse document in the clients medical record?

-Client is itching from medication.
-Client states, “I started to itch after taking that medication.”
-It appears that the client has a rash from the medication.
-Rash from medication noted.

Answer 10

-Client states, “I started to itch after taking that medication.”

Question 11

a nurse is caring for a client who has metastatic cancer and practices Catholicism. The client asks the nurse to discuss the afterlife with them. Which of the following statements by the nurse assists in meeting the clients spiritual needs?

-“Tell me what the afterlife means to you.”
-“You should discuss the afterlife with your priest.”
-“Keep praying. A miracle could happen.”
-“Maybe your condition will lead you closer to God.”

Answer 11

-“Tell me what the afterlife means to you.”

Question 12

a nurse is providing oral hygiene for a client who is unconscious. Identify the sequence of the step the nurse should take.

Answer 12

-asses the gag reflex
-position the client on their side with their head turned to the side
-place a towel under the clients head with an emesis basin under the chin
-separate the clients upper and lower teeth with an oral airway device
-cleanse the clients mouth using a toothbrush

Question 13

a nurse is moving a client up in bed with the assistance of a second nurse. Which of the following actions should the nurse take?

-Stand facing the center of the bed at the client’s side.
-Place feet apart with the foot nearest the head of the client’s bed in front of the other foot.
-Keep knees and hips straight while bending at the waist toward the client.
-Encourage the client to keep their legs straight and remain still.

Answer 13

-Place feet apart with the foot nearest the head of the client’s bed in front of the other foot.

Question 14

a nurse is explaining ethics and values to a newly licensed nurse. The nurse should explain that allowing a client to make a decision about a treatment is an example of which of the following ethical principles?

-Confidentiality
-Nonmaleficence
-Accountability
-Autonomy

Answer 14

Autonomy

Question 15

What statement by a client’s family indicates understanding of hospice care measures?

Answer 15

“We will keep their room cool to help them breathe better.”

Keeping the air in the room cool will ease the work of breathing for clients who are dying.

Question 16

What action should a nurse take to prevent urinary tract infections in a client with an indwelling urinary catheter?

Answer 16

Drain urine from the tubing before ambulating.

This prevents backflow of urine into the bladder.

Question 17

What is a priority modification for a client with partial hearing loss?

Answer 17

Flashing smoke alarm.

This modification allows the client to see when the alarm is activated, enhancing safety.

Question 18

What should a nurse do first after applying clean gloves when removing a client’s peripheral IV catheter?

Answer 18

Clamp the infusion tubing.

This action stops the flow of IV fluid and prevents leakage during removal.

Question 19

What oxygen delivery equipment provides the highest concentration of oxygen?

Answer 19

Nonrebreather mask.

It provides the highest percentage of oxygen concentration without intubation.

Question 20

What finding should a nurse report to the provider for an older adult client?

Answer 20

The client reports urinary incontinence.

Urinary incontinence is an abnormal condition that should be investigated.

Question 21

What intervention should a nurse use when feeding a client with dysphagia?

Answer 21

Instruct the client to tilt their head forward while eating.

This facilitates swallowing and prevents aspiration.

Question 22

What statement by a client after a total bilateral mastectomy requires immediate action?

Answer 22

“When I look at myself in the mirror, I don’t know if I can go on.”

This indicates potential suicidal ideation, requiring immediate intervention.

Question 23

What statement indicates understanding of advance directives for a client with end-stage renal disease?

Answer 23

“I know that I can change my advance directives if I need to in the future.” ## Footnote Clients can change their advance directives at their discretion.

Question 24

What interventions should a nurse include for a disoriented client at risk for falls?

Answer 24

Ensure that the client is wearing non-skid slippers, place the client in a room near the nurses’ station, and reinforce teaching about how to use the call bell. ## Footnote These actions help prevent falls and ensure safety.

Question 25

For which client should a nurse use the therapeutic communication technique of silence?

Answer 25

A client who has just experienced the death of their child. ## Footnote Silence demonstrates caring and allows the client to speak when ready.

Question 26

What ethical principle is demonstrated by allowing a client to make a treatment decision?

Answer 26

Autonomy. ## Footnote Autonomy protects a client's independence and right to make decisions about care.

Question 27

What information should a nurse provide about HIPAA?

Answer 27

Mandates protection of the client's confidential health care information, sets standards for the electronic exchange of health care information, creates clients' right to consent to the disclosure of their protected health information. ## Footnote HIPAA limits sharing of protected health information to those who need it for care.

Question 28

What action should a nurse take to encourage therapeutic communication with a client who has advanced cancer?

Answer 28

Let the client know that, as their nurse, they are available and willing to listen. ## Footnote Active listening conveys respect and acceptance for the client's feelings.

Question 29

What instruction should a nurse provide to a caregiver of a client who is near death?

Answer 29

“Provide mouth care to them at least every 2 hours.” ## Footnote This helps reduce discomfort from dehydration and dry mucous membranes.

Question 30

What intervention should a nurse recommend for a client with minimal sunlight exposure?

Answer 30

Take vitamin D supplements. ## Footnote The body requires sunlight to synthesize vitamin D.

Question 31

What instruction should a nurse include for a client with pneumonia and a productive cough?

Answer 31

“You should cover your mouth with a tissue when you cough.” ## Footnote This helps contain secretions and avoid spreading the infection.

Question 32

What action should a nurse complete prior to family viewing a deceased client?

Answer 32

Clean soiled areas of the body. ## Footnote This ensures dignity and respect for the deceased.

Question 33

What action should a nurse take when administering topical medication?

Answer 33

Compare the label of the medication container with the medication administration record three times. ## Footnote This ensures the correct medication is being administered.

Question 34

What instruction should a nurse include for a client about self-administration of ophthalmic drops?

Answer 34

“You should cleanse your eye from the inner to the outer edge by putting in the drops.” ## Footnote This prevents contamination of the lacrimal duct.

Question 35

What statement indicates understanding of blood pressure measurement for a client with hypertension?

Answer 35

“I should remove constrictive clothing prior to measuring my blood pressure.” ## Footnote Constricted clothing can cause falsely elevated readings.

Question 36

What action should a nurse take to prevent transmission of C-Diff infection?

Answer 36

Remove the cover gown in the client room after providing care. ## Footnote This is part of contact precautions to prevent the spread of infection.

Question 37

What action by an assistive personnel requires intervention by the nurse during postmortem care?

Answer 37

Removing the client's dentures. ## Footnote Dentures should remain in place for a natural appearance.

Question 38

What action should a nurse take when removing staples from a client's incision?

Answer 38

Remove the staple from the skin AFTER both sides are visible. ## Footnote This prevents pulling on the skin and minimizes discomfort.

Question 39

What position should a nurse assist a client with dyspnea caused by a respiratory infection into?

Answer 39

Orthopneic position. ## Footnote This position allows maximal chest expansion and facilitates breathing.

Question 40

What is the first action a nurse should take for a client receiving intermittent enteral feedings?

Answer 40

Measure the client’s gastric residual before each feeding. ## Footnote This is an assessment step in the nursing process.

Question 41

What information should a nurse include in a transfer report for a client moving to a long-term facility?

Answer 41

Resolved health conditions. ## Footnote Reporting both unresolved and resolved conditions promotes continuity of care.

Question 42

What action should a nurse take for a client with active TB?

Answer 42

Assign the client to a negative-pressure airflow room. ## Footnote This prevents air circulation throughout the facility.

Question 43

What finding should a nurse report to the provider regarding urine output?

Answer 43

Urine output of 200mL over 8hrs. ## Footnote This indicates potential kidney malfunction and should be reported.

Question 44

What is the proper crutch gait for a client who needs to keep weight off their right leg?

Answer 44

Three-point gait. ## Footnote This provides two points of support at all times.

Question 45

What action should a nurse take to ensure safety for a client on oxygen at 7L/min via a simple face mask?

Answer 45

Attach a humidifier to the base of the flow meter. ## Footnote This prevents drying mucous membranes.

Question 46

What supplies should a nurse use for wound irrigation of a stage 3 pressure injury?

Answer 46

A piston syringe. ## Footnote This provides a gentle flow of solution to flush the wound.