ATI Fundamentals CMS Exam |
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1. A nurse is caring for a client who has terminal liver cancer. Which of the
following statements should the nurse identify as an indication that the
client is experiencing spiritual distress?
"What could I have done to deserve this illness?"
"I blame medical science for not curing me."
"Where is my daughter at a time like this?"
"Will I ever begin to feel in charge of my life again?"
"What could I have done to deserve this illness?"
The client's terminal illness might prompt the client to review their life
and question its meaning. A manifestation of the client's spiritual
distress is asking why this illness is happening to them.
2. A nurse is preparing to transfer a client who can bear weight on one leg
from the bed to a chair. After securing a safe environment, which of the
following actions should the nurse take next?
Rock the client up to a standing position.
Pivot on the foot that is the farthest from the chair.
Assess the client for orthostatic hypotension.
Apply a gait belt to the client.
, Assess the client for orthostatic hypotension.
The first action the nurse should take when using the nursing process
is to assess the client. The nurse should determine the client's risk for
falling or fainting during the transfer by assisting the client to sit and
dangle the feet on the side of the bed. The nurse should assess for
dizziness and a significant drop in blood pressure before assisting the
client to stand and transfer into the chair.
3. A nurse is giving change-of-shift report about a client they admitted
earlier that day who has pneumonia. Which of the following pieces of
information is the priority for the nurse to provide?
Admitting diagnosis
Breath sounds
Body temperature
Diagnostic test results
Breath sounds
When using the airway, breathing, circulation approach to client care,
the nurse should determine that the priority information to provide is
the current status of the client's breath sounds.
4. A nurse is reviewing practice guidelines with a group of newly licensed
nurses. Which of the following interventions should the nurse include
that is within the RN scope of practice?
, Insert an implanted port.
Close a laceration with sutures.
Place an endotracheal tube.
Initiate an enteral feeding through a gastrostomy tube.
Initiate an enteral feeding through a gastrostomy tube.
It is within the RN scope of practice for nurses to initiate enteral
feedings through nasoenteric, gastrostomy, and jejunostomy tubes.
5. A nurse is caring for a client who requires a 24-hr urine collection. Which
of the following statements by the client indicates an understanding of
the teaching?
"I had a bowel movement, but I was able to save the urine."
"I have a specimen in the bathroom from about 30 minutes ago."
"I flushed what I urinated at 7:00 a.m. and have saved all urine since."
"I drink a lot, so I will fill up the bottle and complete the test quickly."
"I flushed what I urinated at 7:00 a.m. and have saved all urine
since."
For a 24-hr urine collection, the client should discard the first voiding
and save all subsequent voidings.
6. A nurse in the emergency department (ED) is caring for a client.
Click to highlight the findings that indicate the client is
malnourished. To deselect a finding, click on the finding again.
Cachectic, with flaccid muscle tone.
, Skin dry and scaly with bruises on extremities.
Oriented x 3, able to move all extremities.
Pulse rate 118/min
Respiratory rate 18/min
Abdomen distended
Temperature 39.2° C (102.6° F)
BMI 17
Cachectic
Skin dry and scaly...
Pulse Rate
Abdomen distended
BMI 17
Cachectic, with flaccid muscle tone is correct. The client’s lack of
energy, flaccid muscle tone, and wasting appearance can be an
indication of malnutrition.
Skin dry and scaly with bruises on extremities is correct. The
client's dry, scaly, and bruised skin can be an indication of
malnutrition.
Oriented x 3, able to move all extremities is incorrect. The client's
neurological status is within expected parameters.
Pulse rate 118/min is correct. The client's tachycardia can be an
indication of malnutrition.
Respiratory rate 18/min is incorrect. The client's respiratory rate is
within the expected reference range.
Abdomen distended is correct. The client’s abdominal distention
can be an indication of malnutrition.
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