CMS practice exam 108 Questions with Verified Answers,100% CORRECT

CMS practice exam 108 Questions with Verified Answers a nurse is reinforcing teaching about the use of crutches with a client who has a fractured right tibia and fibula. which of the following statements indicates understanding? - CORRECT ANSWER "I will be sure to keep the crutch tips dry" a client who had a recent BTK amputation says, "I don't know how I can continue to live my life without my leg." which is the appropriate response? - CORRECT ANSWER tell me what concerns you have about your future a nurse is preparing to administer oxygen to a client with HF and severe difficulty breathing. which of the following oxygen delivery equipment should the nurse select to provide the highest concentration of oxygen to the client? - CORRECT ANSWER nonrebreather mask intake for a client in 8 hours 150mL/hr IV 120mL juice 500mL water - CORRECT ANSWER 1820mL a charge nurse is reinforcing teaching with an AP about performing pulse oximetry. which of the following information should be included in the teaching? - CORRECT ANSWER remove polish from the clients fingers before applying a nurse is reinforcing teaching with a client about using guided imagery. which of the following actions should the nurse take? - CORRECT ANSWER direct the client to visualize tension leaving the body a nurse is preparing to administer topical medication to a client. which of the following actions should the nurse take? - CORRECT ANSWER compare the label of the medication container with the MAR 3 times a nurse is assisting with the plan of care for a client with aphasia following a stroke. which of the following interventions should the nurse use to assist the client with communication? - CORRECT ANSWER ask close-ended questions a nurse is caring for a. client who has metastatic cancer and practices Catholicism. the client asks the nurse to discuss the afterlife with her. which of the following statements by the nurse assists in meeting the client's spiritual needs? - CORRECT ANSWER "tell me what the afterlife means to you" a nurse is contributing to the plan of care for a client who has a prescription for elastic bandages to the lower extremities. which of the following actions should the nurse recommend for the plan of care? - CORRECT ANSWER compare pedal pulses bilaterally every 4 hours nurse finds a fire. what should she do? RACE - CORRECT ANSWER Evacuate clients Pull the fire alarm Close the fire doors Use the fire extinguisher a nurse in a LTC facility is contributing to the care plan for a client at risk for pressure ulcers. which recommendations should be included in the plan? - CORRECT ANSWER perform a thorough skin inspection each day a nurse is planning to perform wound irrigation for a client who has a large abdominal wound. which of the following actions should the nurse plan to take? - CORRECT ANSWER administer an analgesic 30 minutes prior to beginning a nurse is assisting with the plan of care for 4 clients. Which of the following should the nurse assign to the AP? - CORRECT ANSWER assist a client to get out of bed after a breathing treatment a nurse is preparing to remove a client's peripheral IV catheter. After performing hand hygiene and applying clean gloves, which of the following actions should the nurse take first? - CORRECT ANSWER clamp the infusion tubing a nurse is reinforcing teaching about hospice measures with a family of a client. Which of the following statements indicates an understanding of the teaching? - CORRECT ANSWER "we will keep the room cool to help her breathe better" a nurse is speaking with a client who had DM II and a prescription for insulin. the client verbalize anger about having to take insulin. which of the following responses should the nurse make" - CORRECT ANSWER "I see that you are angry. Let's sit down and talk about it." a nurse is caring for a client refusing medical treatment. Which of the following actions should the nurse take? - CORRECT ANSWER document the client's refusal of the treatment a nurse is preparing to administer an enteral feeding to a client who has an NG tube in place. Which of the following methods should the nurse take to verify placement - CORRECT ANSWER check the pH of the aspirate a client who has advanced cancer tells the nurse that he has a difficult time talking to anyone about the illness. Which of the following actions should the nurse take to encourage therapeutic communication? - CORRECT ANSWER let the client know the he is available and willing to listen a nurse is reinforcing teaching with a client who has hearing loss about how to modify his home environment. which of the following is a priority modification that the nurse should include? - CORRECT ANSWER flashing smoke alarm a nurse is reinforcing teaching with a client about the prevention of stress injuries. which of the following instructions should the nurse include? - CORRECT ANSWER "when lifting a heavy object, keep it close to your body" a nurse is caring for a client who is receiving continuous NG tube feedings. the nurse listens to the client's bowel sounds which of the following actions should the nurse take - CORRECT ANSWER decrease rate of feeding a nurse is assisting with the administration of a client who has active TB. which of the following actions should the nurse plan to take? - CORRECT ANSWER assign the client to a negative pressure air flow room a nurse is reinforcing dietary teaching with a client who has chronic kidney disease and requires a low K+ diet. which of the following food choices by the client demonstrates and understanding - CORRECT ANSWER applesauce a nurse is caring for a disorientated client at high risk for falls. which of the following actions should the nurse take? SATA - CORRECT ANSWER -nonskid slippers -room near the nurses station -reinforce call light teaching a nurse is reinforcing teaching about health promotions with a group of young adults. Which information should the nurse include? - CORRECT ANSWER dental assessment every 6 months a nurse has delegated various client care asks to the APs. which of the following actions by the AP should the nurse identify as correct? - CORRECT ANSWER wearing a mask to get the vital signs of a client with pertussis a nurse is caring for a client who has a NG tube and getting continuous feeding. which of the following actions should the nurse take? - CORRECT ANSWER hold the feeding for 2 consecutive gastric residuals greater than 250mL a nurse is reinforcing teaching with a client about smoking cessation. which of the following is the first stage of health behavior change? - CORRECT ANSWER precontemplation a nurse is reinforcing teaching about carbon monoxide poisoning. which of the following should be included? - CORRECT ANSWER headaches are a common manifestation a nurse is providing wound care for a group of clients. which of the following wounds should be identified as healing by secondary intention? - CORRECT ANSWER stage 3 pressure ulcer a nurse is moving a client up in bed with assistance of a second nurse. which pf the following actions should the nurse take? - CORRECT ANSWER place feet apart with the foot nearest the HOB in front of the other foot a nurse is explaining ethics and values to a newly licensed nurse. the nurse should explain that allowing the client to make decisions about treatment is an example of which of the following principles? - CORRECT ANSWER autonomy a nurse is caring for a client who has an indwelling urinary catheter. which of the following actions should the nurse take to prevent UTIs? - CORRECT ANSWER drain the urine from the tubing before ambulation a nurse is caring for a female client who has urinary incontinence. which of the following actions should the nurse take? - CORRECT ANSWER apply a moisture barrier to the peri area a nurse is repositioning a client who has quadriplegia and in a supine position. which of the following actions should the nurse take to prevent client musculoskeletal injury? - CORRECT ANSWER internally rotate the hips by using the trochanter roll a nurse is reviewing the medical record of a client who has heart failure. which of the laboratory results suggests fluid volume excess? - CORRECT ANSWER BUN 8 a nurse is using Maslow's hierarchy of needs in assisting with discharge planning. which of the following activities is a priority? - CORRECT ANSWER attend an exercise program a nurse is caring for a client with a K+ supplement. the client says the pill is too large to swallow and refuses to take it. the nurse offers to break it into two smaller pieces. which of the following ethics principles was demonstrated? - CORRECT ANSWER beneficence a client has a positive throat culture for streptococci. which intervention should be included in the plan of care? - CORRECT ANSWER ensure the client were a surgical mask during transportation through the facility a client has a bacterial infection and a persistent oral temperature of 38.9 (102). which of the following interventions should the nurse include in the plan of care to treat the fever? - CORRECT ANSWER administer acetaminophen a nurse is caring for a client who has recently undergone a bilateral mastectomy. which of the following statement by the client requires immediate action by the nurse? - CORRECT ANSWER "when I look at myself in the mirror, I don't know if I can go on." a nurse is contributing to a plan of care for a client with a prescription for a wrist restraint. which actions should be included in the plan? - CORRECT ANSWER pad the bony prominences a nurse is reinforcing preoperative teaching with a client who does not speak the same language. which action should the nurse take? - CORRECT ANSWER provide handouts written in the client's primary language a nurse writes client information on a paper while receiving report. how should the nurse dispose of the paper? - CORRECT ANSWER shred it a nurse is caring for a client who is postoperative and experiencing N/V. which of the following findings indicates the client has fluid volume deficit? - CORRECT ANSWER -decreased skin turgor -orthostatic hypotension -flat neck veins a nurse is caring for client with C. diff. which of the following solutions should the nurse use to perform hand hygiene while caring for this client? - CORRECT ANSWER mild soap a nurse is assisting with a presentation to a group of older adults about hypothermia and hyperthermia. which of the following information should the nurse include about age-related changes? - CORRECT ANSWER circulation becomes less efficient with age a nurse is reinforcing teaching with a client about oral hygiene. which of the following instructions should the nurse include in the teaching? - CORRECT ANSWER replace toothbrush following an illness a nurse is assisting with admission of a client who brought her own medication to the facility. which of the following actions should the nurse take? - CORRECT ANSWER compare the medication the provider has prescribed with the medications from home a nurse is reinforcing teaching with a client who reports inability to sleep. which information should the nurse include when teaching about aging and sleep? - CORRECT ANSWER sleep patterns change with age a nurse is collecting data from an older client. which of the following finding should the nurse report to the provider? - CORRECT ANSWER the client reports urinary incontinence a nurse is caring for a client who is alert in a LTC facility. which of the following actions should the nurse take to protect the clients privacy? - CORRECT ANSWER ask the client before discussing his condition when family is present a nurse is collecting data from a client who has an NG tube set to low intermittent suction. which of the following findings indicates hypomagnesemia? - CORRECT ANSWER positive Chvostek's sign a nurse is palpating the pulse located on the top of a client's foot. which of the following pulses should the nurse document she is palpating? - CORRECT ANSWER dorsalis pedis a nurse is reinforcing teaching with a client getting PCA. which of the following statements indicates an understanding of the teaching? - CORRECT ANSWER " I will not let anyone press the button for me" a nurse is reinforcing teaching with a client who has a prescription for a TENS unit. which information should the nurse include? - CORRECT ANSWER place the electrodes near the pain site The home health nurse visits an elderly female client who had a brain attack three months ago and is now able to ambulate with the assistance of a quad cane. Which assessment finding has the greatest implications for this client's care? - CORRECT ANSWER The nurse notes that there are numerous scatter rugs throughout the house. The nurse is digitally removing a fecal impaction for a client. The nurse should stop the procedure and take corrective action if which client reaction is noted? - CORRECT ANSWER Pulse rate decreases from 78 to 52 beats/min. . The nurse is providing passive range of motion (ROM) exercises to the hip and knee for a client who is unconscious. After supporting the client's knee with one hand, what action should the nurse take next? - CORRECT ANSWER Cradle the client's heel. A client who has moderate, persistent, chronic neuropathic pain due to diabetic neuropathy takes gabapentin (Neurontin) and ibuprofen (Motrin, Advil) daily. If Step 2 of the World Health Organization (WHO) pain relief ladder is prescribed, which drug protocol should be implemented? - CORRECT ANSWER Continue gabapentin The nurse is preparing to irrigate a client's indwelling urinary catheter using an open technique. What action should the nurse take after applying gloves? - CORRECT ANSWER Draw up the irrigating solution into the syringe. Which client care requires the nurse to wear barrier gloves as required by the protocol for Standard Precautions? - CORRECT ANSWER • Emptying the urinary catheter drainage bag for a client with Alzheimer's disease. What action should the nurse implement to prevent the formation of a sacral ulcer for a client who is immobile? - CORRECT ANSWER • Position prone with a small pillow below the diaphragm What intervention should the nurse include in the plan of care for a client who is being treated with an Unna's paste boot for leg ulcers due to chronic venous insufficiency? - CORRECT ANSWER Check capillary refill of toes on lower extremity with Unna's paste boot The nurse is administering an intermittent infusion of an antibiotic to a client whose intravenous (IV) access is an antecubital saline lock. After the nurse opens the roller clamp on the IV tubing, the alarm on the infusion pump indicates an obstruction. What action should the nurse take first? - CORRECT ANSWER • Reposition the client's arm. A female client who has breast cancer with metastasis to the liver and spine is admitted with constant, severe pain despite around-the-clock use of oxycodone (Percodan) and amitriptyline (Elavil) for pain control at home. During the admission assessment, which information is most important for the nurse to obtain? - CORRECT ANSWER • Sensory pattern, area, intensity, and nature of the pain A male client is on contact precautions due to an infected draining wound and is being discharged home. The client lives at home with his wife and their adolescent daughter. What discharge instruction should the nurse include for the client? - CORRECT ANSWER • Dispose of soiled dressings in plastic bags that are securely closed. The nurse is discussing dietary preferences with a client who adheres to a vegan diet. Which dietary supplement should the nurse encourage the client to include the dietary plan? - CORRECT ANSWER Vitamin B12 The charge nurse observes that a demographic screen has been left open on a hallway computer by a nurse who is responding to a call light because the unlicensed assistive personnel (UAP) is involved in a personal phone call. Which action should the charge nurse take first? - CORRECT ANSWER • Close the demographic screen on the computer A female client informs the nurse that she uses herbal therapies to supplement her diet and manage common ailments. What information should the nurse offer the client about general use of herbal supplements? - CORRECT ANSWER Herbs should be obtained from manufacturers with a history of quality control of their supplements. A high school senior is complaining of a persistent cough and admits to smoking 10 to 15 cigarettes daily for the past year. He is convinced that he is hopelessly addicted to tobacco since he tried unsuccessfully to quit smoking last week. Which intervention is best for the nurse to implement? - CORRECT ANSWER Encourage the student to associate with non-smokers only while attempting to stop smoking. When making the bed of a client who needs a bed cradle, which action should the nurse include? - CORRECT ANSWER Drape the top sheet and covers loosely over the bed cradle A male client with acquired immunodeficiency syndrome (AIDS) develops cryptococcal meningitis and tells the nurse he does not want to be resuscitated if his breathing stops. What action should the nurse implement? - CORRECT ANSWER Ask the client if this decision has been discussed with his healthcare provider A client is admitted to the hospital with intractable pain. What instruction should the nurse provide the unlicensed assistive personnel (UAP) who is preparing to assist this client with a bed bath? - CORRECT ANSWER Take measures to promote as much comfort as possible An older client who is able to stand but not to ambulate receives a prescription to be mobilized into a chair as tolerated during each day. What is the best action for the nurse to implement when assisting the client from the bed to the chair? - CORRECT ANSWER Place a transfer belt around the client, assist to stand, and pivot to a chair that is placed at a right angle to the bed. Correct A male client has a nursing diagnosis of "spiritual distress." What intervention is best for the nurse to implement when caring for this client? - CORRECT ANSWER Use reflective listening techniques when the client expresses spiritual doubts. The nurse obtains a BP reading of 100/88 in the right arm of a client whose blood pressure is typically 120/60 in the same arm. What action should the nurse implement first? - CORRECT ANSWER Retake the blood pressure in the same arm, deflating the cuff slowly A client has a nursing diagnosis of, "Spiritual distress related to a loss of hope, secondary to impending death." What intervention is best for the nurse to implement when caring for this client? - CORRECT ANSWER Assist and support the client in establishing short-term goals. What is the most effective way to implement a teaching plan? - CORRECT ANSWER Teach the information that the client wants to learn first An older female client with rheumatoid arthritis is complaining of severe joint pain that is caused by the weight of the linen on her legs. What action should the nurse implement first? - CORRECT ANSWER Drape the sheets over the footboard of the bed. . A male nurse is assigned to care for a female Muslim client. When the nurse offers to bathe the client, the client requests that a female nurse perform this task. How should the male nurse respond? - CORRECT ANSWER I will ask one of the female nurses to bathe you A female client informs the nurse that she uses herbal therapies to supplement her diet and manage common ailments. What information should the nurse offer the client about general use of herbal supplements? - CORRECT ANSWER Herbs should be obtained from manufacturers with a history of quality control of their supplements A client is admitted with a stage four pressure ulcer that has a black, hardened surface and a light-pink wound bed with a malodorous green drainage. Which dressing is best for the nurse to use first? - CORRECT ANSWER Wet to moist dressing. When preparing to insert an indwelling urinary catheter, the nurse applies sterile gloves and then tests the catheter balloon for patency. What action should the nurse implement next? - CORRECT ANSWER Apply a sterile lubricant to the end of the catheter. The nurse is teaching a client how to self-administer a subcutaneous injection. To help ensure sterility of the procedure, which subject is most important for the nurse to include in the teaching plan? - CORRECT ANSWER Method used to aspirate medication from a vial. A nurse observes a student nurse taking a copy of a client's medication administration record. When questioned, the student states, Another student is scheduled to administer medications for this client tomorrow, so I am going to make a copy to help my friend prepare for tomorrow's clinical. What response should the nurse provide first? - CORRECT ANSWER Explain that the records are hospital property and may not be removed. Which action should the nurse implement when using the confrontation technique during a vision exam? - CORRECT ANSWER Sit facing the client and while look directly at the client's face, move an object inward from the periphery. What action should the nurse implement to prevent the formation of a sacral ulcer for a client who is immobile? - CORRECT ANSWER Position prone with a small pillow below the diaphragm. When culturing a wound, the nurse should obtain the sample from which part of the wound? - CORRECT ANSWER Areas containing purulent or pooled exudates. Before administering a client's medication, the nurse assesses a change in the client's condition and decides to withhold the medication until consulting with the healthcare provider. After consultation with the healthcare provider, the dose of the medication is changed and the nurse administers the newly prescribed dose an hour later than the originally scheduled time. What action should the nurse implement in response to this situation? - CORRECT ANSWER Document the events that occurred in the nurses' notes. A healthcare provider is performing a sterile procedure at a client's bedside. Near the end of the procedure, the nurse observes the healthcare provider contaminate a sterile glove and the sterile field. What is the best action for the nurse to implement? - CORRECT ANSWER Identify the break in surgical asepsis and provide another set of sterile supplies. The nurse is caring for a client who is weak from inactivity because of a 2-week hospitalization. In planning care for the client, the nurse should include which range of motion (ROM) exercises? - CORRECT ANSWER Active ROM exercises to both arms and legs two or three times a day. A male client is on contact precautions due to an infected draining wound and is being discharged home. The client lives at home with his wife and their adolescent daughter. What discharge instruction should the nurse include for the client? - CORRECT ANSWER Dispose of soiled dressings in plastic bags that are securely closed. A 35-year-old female client with cancer refuses to allow the nurse to insert an IV for a scheduled chemotherapy treatment, and states that she is ready to go home to die. What intervention should the nurse initiate? - CORRECT ANSWER Evaluate the client's mental status for competence to refuse treatment What is the most effective way to implement a teaching plan? - CORRECT ANSWER Teach the information that the client wants to learn first A client is receiving an intramuscular injection at the ventrogluteal site. At what angle should the nurse insert the needle? - CORRECT ANSWER 90 A client who has been on bedrest for several days now has a prescription to progress activity as tolerated. When the nurse assists the client out of bed for the first time, the client becomes dizzy. What action should the nurse implement? - CORRECT ANSWER Advise the client to sit on the side of the bed for a few minutes before standing again When examining the wound of a client who had abdominal surgery yesterday, the nurse finds that the wound edges are close together, there is no sign of redness, and there is a slight amount of bright red blood oozing from the incision. What action should the nurse take? - CORRECT ANSWER Record these findings in the client's record The nurse assesses an immobile, elderly male client and determines that his blood pressure is 138/60, his temperature is 95.8° F, and his output is 100 ml of concentrated urine during the last hour. He has wet-sounding lung sounds, and increased respiratory secretions. Based on these assessment findings, what nursing action is most important for the nurse to implement? - CORRECT ANSWER Turn the client q2h The nurse is preparing to perform oral care for an unconscious client. In what order should the nurse implement the nursing actions? (Arrange the options in the order they should be performed with the first action on top and the last action on the bottom. - CORRECT ANSWER 1. Raise bed to a comfortable working height. 2. Lower the side rail between the nurse and the client. 3. Position the client in a flat side-lying position. 4. Place an emesis basin under the client's chin. The nurse is preparing a male client who has an indwelling catheter and an IV infusion to ambulate from the bed to a chair for the first time following abdominal surgery. What action(s) should the nurse implement prior to assisting the client to the chair? (Select all that apply.) - CORRECT ANSWER Pre-medicate the client with an analgesic. Inform the client of the plan for moving to the chair. Ask the client to push the IV pole to the chair • Assess the client's blood pressure. When caring for an immobile client, what nursing diagnosis has the highest priority? - CORRECT ANSWER Impaired gas exchange. What action should the nurse implement when adding sterile liquids to a sterile field? - CORRECT ANSWER • Consider the sterile field contaminated if it becomes wet during the procedure. The nurse is preparing to irrigate a client's indwelling urinary catheter using an open technique. What action should the nurse take after applying gloves? - CORRECT ANSWER Draw up the irrigating solution into the syringe. When assessing a client with a nursing diagnosis of fluid volume deficit, the nurse notes that the client's skin over the sternum "tents" when gently pinched. Which action should the nurse implement? - CORRECT ANSWER Continue the planned nursing interventions to restore the client's fluid volume The daughter of an older woman who became depressed following the death of her husband asks, "My mother was always well-adjusted until my father died. Will she tend to be sick from now on?" Which response is best for the nurse to provide? - CORRECT ANSWER It's highly likely that she will recover and return to her pre-illness state.