CMS FUNDAMENTALS PROCTORED EXAM 2024/2025 QUESTIONS AND CORRECT ANSWERS (100% COMPLETE)

CMS FUNDAMENTALS PROCTORED EXAM Ch. 1) 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 - ANSWER- A, B, D Rationale: A. Restorative health care involves immediate follow up care for restoring health and prolonged self-care home healthcare is a type of restorative healthcare B. Rehabilitation facilities are a type of restorative health care D. Skilled nursing facilities are a type of restorative healthcare Ch. 1) A nurse is explaining the various types of health clients might have to a group care coverage of nurses. Which of the following health care financing mechanisms should the nurse include as 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 - ANSWER- B, E Rationale: Medicare and Medicaid are federally funded. PPOs, Long-term care insurance and EPOs are privately funded Ch. 1) 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 health care 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 in surgical treatments for obesity D. Educating acute care nurses about postoperative complications related to obesity - ANSWER- A Rationale: identify obesity screenings at office visit as an example of primary healthcare. primary healthcare emphasizes health promotion and disease control, is often delivered during office visit, and includes screenings. Ch. 1) A nurse is discussing the purpose of regulatory agencies during a staff meeting. Which of the following tasks should the nurse identify as the responsibility of state licensing boards? A. Monitoring evidence-based practice for clients who have a specific diagnosis B. Ensuring that health care providers comply with regulations C. Setting quality standards for accreditation of health care facilities D. Determining whether medications are safe for administration to clients - ANSWER- B Rationale: identify that state licensing boards are responsible for ensuring that healthcare providers and agencies comply with state regulations. Ch. 1) A nurse is explaining the various levels of health care services to a group of newly licensed nurses. Which of the following examples of care or care settings should the nurse classify as tertiary care? (Select all that apply) A. Intensive care unit B. Oncology treatment center C. Burn center D. Cardiac rehabilitation E. Home health care - ANSWER- A, B, C Rationale: tertiary healthcare involves the provision of specialized and highly technical care (icu, oncology treatment center, and burn centers) Ch. 2) 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 the home. B. A client asks about community resources available for older adults. C. A client states, "I would like to have my child baptized before surgery." D. A client requests an electric wheelchair for use after discharge. E. A client states, "I do not understand how to use a nebulizer." - ANSWER- A, B, D Rationale: A. initiate a referral for a social worker to provide information and assistance in coordinating hospice care for a patient B. Initiate a referral for a social worker to provide information and assistance in coordinating care for community resources available for clients D. Initiate a referral for a social worker to assist the client in obtaining medical equipment for use after discharge Ch. 2) 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 - ANSWER- D Rationale: an occupational therapist can assist clients who have physical challenges to use adaptive devices and strategies to help with self-care activities Ch. 2) A client who is postoperative following knee arthroplasty is concerned about the adverse effects of the medication prescribed for pain management. Which of the following members of the interprofessional care team can assist the client in understanding the medication's effects? (Select all that apply.) A. Provider B. Certified nursing assistant C. Pharmacist D. Registered nurse E. Respiratory therapist - ANSWER- A, C, D Rationale: A. The provider must be knowledgeable about any medication prescribed for the client including its actions, effects, and interactions C. A pharmacist must be knowledgeable about any medication dispensed for the client, including its actions, effects, and interactions. D. A registered nurse must be knowledgeable about any medication administered, including its actions, effects, and interactions. Ch. 2) A client who had a cerebrovascular accident has persistent problems with dysphagia. The nurse caring for the client should initiate a referral with which of the following members of the interprofessional care team? A. Social worker B. Certified nursing assistant C. Occupational therapist D. Speech-language pathologist - ANSWER- D Rationale: A speech language pathologist can initiate specific therapy for clients who have difficulty with feeding due to swallowing difficulties Ch. 2) A nurse is acquainting a group of newly licensed nurses with the roles of the various members of the health care team they will encounter on a medical-surgical unit. When providing examples of the types of tasks certified nursing assistants (CNAS) can perform, which of the following client activities should the nurse include? (Select all that apply.) A. Bathing B. Ambulating C. Toileting D. Determining pain level E. Measuring vital signs - ANSWER- A, B, C, E Rationale: it is within the range of function for a CNA to provide basic care to patients (bathing, assisting with ambulation, assisting with toileting, measuring and recording vital signs) Ch. 4) A nurse observes an assistive personnel (AP) reprimanding a client for not using the urinal properly. The AP tells the client that diapers will be used next time the urinal is used improperly. Which of the following torts is the AP committing? A. Assault B. Battery C. False imprisonment D. Invasion of privacy - ANSWER- A Rationale: by threatening the client, the AP is committing a salt. The AP's threats could make the client become fearful and apprehensive. Ch. 4) A nurse is caring for a competent adult client who tells the nurse, "I am leaving the hospital this morning whether the doctor discharges me or not." The nurse believes that this is not in the client's best interest, and prepares to administer a PRN sedative medication the client has not requested along with the scheduled morning 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 - ANSWER- B Rationale: administering a medication as a chemical restraint to keep the client from leaving the facility against medical advice is false imprisonment, because the client neither requested nor consented to receiving the sedative. Ch. 4) 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 "I plan to prepare my advance directives before I come 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." - ANSWER- C Rationale: The patient has the right to decide and specify which medical procedures he wants when a life-threatening situation arises. Ch. 4) 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's 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. - ANSWER- A, B Rationale: it is the nurses responsibility to verify that The surgeon obtained the clients consent and that the client understands the information the surgeon gave them AND witness the client signing of the consent form, and to verify that they are consenting voluntarily and appear to be competent to do so. The nurse should also verify that the client understands the information the surgeon has provided. Ch. 4) A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy and unable to focus on the issue at hand. Today, the nurse was found asleep in a chair in the break room not during a break time. Which of the following actions should the nurse take? A. Alert the American Nurses Association. B. Fill out an incident report. C. Report the observations to the nurse manager on the unit. D. Leave the nurse alone to sleep. - ANSWER- C Rationale: any nurse who notices behavior that could jeopardize client care or could indicate a substance use disorder has a duty to report the situation immediately to the nurse manager. Ch. 5) 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 - ANSWER- C Rationale: The bone scan is important because the nurse might have to modify the clients care to accommodate leaving the unit Ch. 5) A nurse manager is discussing the HIPAA Privacy Rule with a group of newly hired nurses during orientation. Which of the following information should the nurse manager 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 their medical record. E. A nurse can photocopy a client's medical record for transfer to another facility. - ANSWER- B, C, D, E Rationale: B. The HIPAA privacy rule states that information should only be disclosed to authorized individuals to whom the client has provided consent. Many hospitals use a code system that identifies these individuals and should only provide information if the individual can give the code C. The HIPAA privacy rule states that communication about a client should only take place in a private setting we're on authorized individuals cannot overhear it. A unit nurses station is considered a private and secure location. D. The HIPAA privacy rule states that clients have a right to read and obtain a copy of their medical record E. The HIPAA privacy rule states that nurses can only photocopy a clients medical record if it is to be used for transfer to another facility or provider Ch. 5) A charge 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. - ANSWER- B, C Rationale: B. The date and time confirm the recording of the correct sequence of events C. Documentation must be factual, descriptive, and objective, without opinions or criticism Ch. 3) A nurse is caring for a client who decides not to have surgery despite significant blockages of the 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 - ANSWER- B Rationale: in this situation the client is exercising their right to make their own personal decision about surgery, regardless of others opinions of what is best for them. This is an example of autonomy Ch. 3) 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 - ANSWER- D Rationale: Beneficence is an action that promotes good for others without self interest. By administering pain medication before the client attempts a potentially painful exercise like ambulation, The nurse is taking a specific and positive action to help the client Ch. 3) A nurse is instructing a group of newly licensed nurses 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 newly licensed nurses should understand that this aspect of cared delivery is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence - ANSWER- C Rationale: justice is fairness in care delivery and in the use of resources. By applying the same qualifications to all potential kidney transplant recipients, organ procurement organizations demonstrate this ethical principle in determining the allocation of these scarce resources Ch. 3) A nurse questions a medication prescription as too extreme in light of the client's 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 - ANSWER- D Rationale: Non-malfeasance is a commitment to do no harm. In this situation, administering the medication could harm the patient. By questioning it, the nurse is demonstrating the ethical principle Ch. 3) A nurse is instructing a group of newly licensed nurses about how to know and what to expect when ethical dilemmas arise. Which of the following situations should the newly licensed nurses identify as an ethical dilemma? A. A nurse on a medical-surgical unit demonstrates signs of chemical impairment B. A nurse overhears another nurse telling an older adult client that if he does not 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 their partner on their durable power of attorney form - ANSWER- C Rationale: making the decision about initiating enteral tube feedings is an example of an ethical dilemma. A review of scientific data cannot resolve the issue, and it is not easy to resolve. The decision will have a profound effect on the situation and on the client. Ch. 5) 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 (SATA) A. Medication error B. Needlesticks C. Conflict with provider and nursing staff D. Omission of prescription E. Missed specimen collection of a prescribed laboratory test - ANSWER- A, B, D Rationale: complete an incident report regarding a medication error, a needlestick, and omission of a prescription Ch. 5) 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? (SATA) A. Repeat the details of the prescription back to the provider B. Have another nurse listen to the telephone prescription C. Obtain the provider's signature on the prescription within 24 hours D. Decline the verbal prescription because this is not an emergency situation E. Tell the charge nurse that the provider has prescribed morphine by telephone - ANSWER- A, B, C Rationale: A. The nurse should repeat the medications name, dosage, time or interval, route, and any other pertinent information back to the provider and receive and document confirmation B. Having another nurse listen to the telephone prescription is a safety precaution that helps prevent medication errors due to miscommunication. C. The provider must sign the prescription within the timeframe the facility specifies in its policies generally 24 hours Ch. 6) A nurse on a medical-surgical unit has received change-of-shift report and will care for four patients. Which of the following tasks should the nurse assign the assistive personnel (AP)? A. Updating the plan of care for a client who is postop? B. Reinforcing teaching with a client who is learning to walk using a quad cane C. Reapplying a condom catheter for a client who has urinary incontinence D. Applying a sterile dressing to a pressure injury - ANSWER- C Rationale: The application of a condom catheter is a non-invasive, routine procedure that can be delegated to an AP Ch. 6) A nurse manager is assigning care of a client who is bring admitted from the PACU following thoracic surgery. The nurse manager should assign the client to which of the following staff members? A. Charge nurse B. Registered Nurse C. Practical Nurse D. Assistive Personnel - ANSWER- B Rationale: A client who is post operative following thoracic surgery requires professional nursing knowledge, skills, and judgment of an RN to provide safe and effective client care Ch. 6) A nurse is delegating the ambulation of a client who had a knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP? (SATA) A. The roommate ambulates independently B. The client ambulates wearing slippers over anti embolic stockings C. The client uses a front-wheeled walker when ambulating D. The client had pain medication 30 min ago E. The client is allergic to codeine F. The client ate 50% of breakfast this morning - ANSWER- B, C, D Rationale: to complete this assignment safely, the assistive personnel should make sure the client wear stockings and slippers, uses a front wheeled walker, and the client should be feeling the effects of pain medicine Ch. 6) A charge nurse is assigning client care for four clients. Which of the following tasks should the nurse assign to a PN? A. Creating a plan of care for a client who is recovering following a stroke B. Assessing a pressure injury on a client who is on bed rest C. Providing nasopharyngeal suctioning for a client who has pneumonia D. Teaching a client who has asthma to use a metered-dose inhaler - ANSWER- C Rationale: providing nasopharyngeal suctioning is within the scope of a practical nurse Ch. 6) A nurse is preparing an in-service program about delegation. Which of the following are components of the five rights of delegation (SATA)? A. Right place B. Right supervision and evaluation C. Right direction and communication D. Right documentation E. Right circumstances - ANSWER- B, C, E (rights not in question- person and task) Ch. 7) 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 inadequate pain relief. B. Wait to see whether the pain lessens during the next 24 hr. 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. - ANSWER- A Rationale: collect further data from the client to determine why they have not achieved satisfactory pain relief, because various factors might be interfering with their comfort. The nursing process repeats in an ongoing manner across the span of client care Ch. 7) A charge nurse is observing a newly licensed nurse care for a client who reports pain. The nurse checked the client's MAR and noted the last dose of pain medication was 6 hours ago. The prescription reads every 4 hours PRN for pain. The nurse administered the medication and checked with the client 40 min later, when the client reported improvement. The newly licensed nurse left out which of the following steps in the nursing process? A. Assessment B. Planning C. Intervention D. Evaluation - ANSWER- A Rationale: A newly licensed nurse should have used the assessment step of the nursing process by asking the client to evaluate the severity of pain on a 0 to 10 scale. The nurse should have asked about the characteristics of the pain and assess for any changes that might have contributed to worsening of the pain Ch 31) A nurse in a provider's office is preparing to assess a young adult client's musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (SATA) A. Concave thoracic spine posteriorly B. Exaggerated lumbar curvature C. Concave lumbar spine posteriorly D. Exaggerated thoracic curvature E. Muscles slightly larger on the dominant side - ANSWER- C, E Ch 46 (#1): A nurse is caring for a client who is 1 day postoperative and reports a pain level of 10 on a scale of 0 to 10. After reviewing the client's medication administration record, which of the following medications should the nurse administer? A. Meperidine 75 mg IM B. Fentanyl 50 mcg/hr transdermal patch C. Morphine 2 mg IV D. Oxycodone 10 mg PO - ANSWER- C. Morphine 2 mg IV Rationale: administer IV morphine bc the onset is rapid, and absorption of the medication into the blood is immediate, which provides the optimal response for a client who is reporting pain at a level of 10. Ch 46 (#2): A nurse is teaching a client about medications at discharge. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I can open the time-release capsule with the beads in it and sprinkle them on my oatmeal." B. "If I am having difficulty swallowing, I will add the liquid medication to prepared package of pudding." C. "I can crush the enteric coated pill, if needed." D. "I will eat two crackers with the pain pills." - ANSWER- D. Rationale: Pt should take analgesics with small amounts of food to help prevent N/V. Ch 46 (#3): A nurse is teaching a client how to administer medication through a jejunostomy tube. Which of the following instructions should the nurse include? A. "Flush the tube before and after each medication." B. "Mix your medications with your enteral feeding." C. "Push tablets through the tube slowly." D. "Mix all the crushed medications prior to dissolving them in water." - ANSWER- A. Rationale: Pt should flush tubing before and after each medication with 15-30 mL of water to prevent clogging of the tube. Ch. 52: A nurse is reviewing the medical record of a client who has a blood glucose of 260 mg/dL and no documented history of diabetes mellitus. Which of the following types of medications can cause hyperglycemia as an adverse effect? (Select all that apply.) A. Diuretics B. Corticosteroids C. Oral anticoagulants D. Opioid analgesics E. Antipsychotics - ANSWER- A, B, E Ch. 52: A nurse teaching a client how to check blood glucose levels. The nurse should include which of the following instructions about transferring blood onto the reagent portion of the test strip? A. Smear the blood onto the strip B. Squeeze the blood onto the strip C. Touch the puncture to stimulate bleeding D. Hold the test strip next to the blood on the fingertip - ANSWER- D Ch. 52: A nurse attempting to collect a capillary blood specimen via finger stick for blood glucose monitoring is unable to obtain an adequate drop of blood for the reagent strip. Which of the following actions should the nurse take first? A. Puncture another finger to obtain a capillary specimen B. Test the urine with a urine reagent strip C. Wrap the hand in a warm, moist cloth D. Perform a venipuncture to obtain a venous sample - ANSWER- C Ch. 52: A nurse is teaching self-monitoring of blood glucose (SMBG) to a client who has diabetes mellitus. Which of the following instructions should the nurse include? (Select all that apply.) A. Perform SMBG once daily at bedtime B. Wipe the hand with an alcohol swab C. Hold the hand in a dependent position prior to the puncture D. Place the puncturing device perpendicular to the site E. Prick the outer edge of the fingertip for the blood sample - ANSWER- C, D, E Ch. 53: A nurse is assessing a client who has an acute respiratory infection, increasing the risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxia? (Select all that apply.) A. Restlessness B. Tachypnea C. Bradycardia D. Confusion E. Hypertension - ANSWER- A, B, D, E Ch. 53: A provider is discharging a client who has a prescription for home oxygen therapy via nasal cannula. Client and family teaching by the nurse should include which of the following instructions? (Select all that apply.) A. Apply petroleum jelly around and inside the nares B. Remove the nasal cannula during mealtimes C. Check the position of the cannula frequently D. Report any nausea or difficulty breathing E. Post "No Smoking" signs in prominent locations - ANSWER- C, D, E Ch. 53: A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority. A. Increase the oxygen flow B. Assist the client to Fowler's position C. Promote removal of pulmonary secretions D. Obtain a specimen for arterial blood gases - ANSWER- B Ch 48 (#1): A nurse is preparing to administer methylprednisolone 10 mg by IV bolus. The amount available is methylprednisolone injection 40mg/mL. How many mL should the nurse administer? (Round answer to the nearest tenth. Do not use a trailing zero.) - ANSWER- Answer: 0.3 mL Ch 48 (#2): A nurse is preparing to administer LR IV 100 mL over 15 min. The nurse should set the IV infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Do nose use a trailing zero.) - ANSWER- Answer: 400 mL/hr Ch 48 (#3): A nurse is preparing to administer 0.9% NaCl 250 mL IV to infuse over 30 min. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should adjust the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Do nose use a trailing zero.) - ANSWER- Answer: 83 gtt/min Ch. 54: A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following nursing interventions is the highest priority when the nurse suspects aspiration of the feeding? A. Auscultate breath sounds B. Stop the feeding C. Obtain a chest x-ray D. Initiate oxygen therapy - ANSWER- B Ch. 54: A nurse is preparing to instill an enteral feeding for a client who has an NG tube in place. Which of the following actions is the nurse's highest assessment priority before performing this procedure? A. Check how long the feeding container has been open B. Verify the placement of the NG tube C. Confirm that the client does not have diarrhea D. Make sure the client is alert and oriented - ANSWER- B Ch. 54: A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse complete prior to administering the tube feeding? (Select all that apply.) A. Auscultate bowel sounds B. Assist the client to an upright position C. Test the pH of gastric aspirate D. Warm the formula to body temperature E. Discard any residual gastric contents - ANSWER- A, B, C Ch. 54: A nurse is preparing to insert an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse perform before beginning the procedure? (Select all that apply.) A. Review a signal the client can use if feeling any distress B. Lay a towel across the client's chest C. Administer oral pain medication D. Obtain a Dobhoff tube for insertion E. Have a petroleum-based lubricant available - ANSWER- A, B Ch. 55: A nurse is caring for a client who is 2 days postoperative following an appendectomy and has type I diabetes mellitus. Their Hgb is 12 g/dL and BMI is 17.1. The incision is approximated and free of redness, with scant serous drainage on the dressing. The nurse should recognize that the client has which of the following risk factors for impaired wound healing? (Select all that apply.) A. Extremes in age B. Chronic illness C. Low hemoglobin D. Malnutrition E. Poor wound care - ANSWER- B, C, D Ch 49 (#1): A nurse is demonstrating how to insert an IV catheter. Which of the following statements by a nurse viewing the demonstration indicates understanding of the procedure? A. "I will thread the needle all the way into the vein until the hub rests against the insertion site after I see a flashback of blood." B. "I will insert the needle into the clients skin at an angle of 10-30 degrees with the bevel up." C. "I will apply pressure approximately 1.2 in below the insertion site prior to removing the needle." D. "I will choose a vein in the antecubital fossa for IV insertion due to its size and easily accessible location." - ANSWER- B Ch 49 (#2): A nurse is collecting data from a client who is receiving IV therapy and reports pain in the arm, chills, and 'not feeling well'. The nurse notes warmth, edema, induration, and red, streaking on the clients arm close to the IV insertion site. Which of the following actions should the nurse plan to take first? A. Obtain a specimen for culture. B. Apply a warm compress. C. Administer an analgesic. D. Discontinue the infusion. - ANSWER- D Ch 49 (#3): During a new employee orientation, a nurse is explaining how to prevent IV infections. Which of the following statements by an orientee indicates understanding of the preventative strategies? A. "I will leave the IV catheter in place after the client completes the coarse of IV antibiotics." B. "As long as I am working with the same client, I can use the same IV catheter for the second insertion attempt." C. "If my client needs to use the restroom, it would be safer to disconnect their IV infusions as long as i can clean the injection ports thoroughly with an antiseptic swab." D. "I will replace any IV catheter when I suspect contamination during insertion." - ANSWER- D Ch 49 (#4): A nurse of the IV team is conducting an in-service education program about the complications of IV therapy. which of the following statements by an attendee indicates an understanding of the manifestations of infiltration? (Select all that apply.) A. "A temperature around the IV site is cooler" B. "The rate of the infusion increases" C. "The skin at the IV site is red" D. "The IV dressing is damp." E. "The tissue around the veni puncture site is swollen" - ANSWER- A, D, E Ch. 55: A nurse is collecting data from a client who is 5 days postoperative following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following findings should the nurse expect? (Select all that apply.) A. Increase in incisional pain B. Fever and chills C. Reddened wound edges D. Increase in serosanguineous drainage E. Decrease in thirst - ANSWER- A, B, C Ch. 55: A nurse educator is reviewing the wound healing process with a group of nurses. The nurse educator should include in the information which of the following alterations for wound healing by secondary intention? (Select all that apply.) A. Stage 3 pressure ulcer B. Sutured surgical incision C. Casted bone fracture D. Laceration sealed with adhesive E. Open burn area - ANSWER- A, E Ch 50 (#2) A nurse is teaching a client who has a new prescription for oxybutynin about managing the medication's anticholinergic effects. Which of the following instructions should the nurse include? A. Take sips of water frequently. B. Wear sunglasses when outdoors in sunlight. C. Use a soft toothbrush when brushing teeth. D. Take the medication with an antacid. E. Urinate prior to taking the medication. - ANSWER- A, B, E Ch 50 (#3) A nurse is reviewing a client's medications. They include cimetidine and imipramine. Knowing that cimetidine decreases the metabolism of imipramine, the nurse should identify that this combination is likely to result in which of the following effects? A. Decreases therapeutic effects of cimetidine. B. Increased risk of imipramine toxicity. C. Decreased risk of adverse effects of cimetidine. D. Increased therapeutic effects of imipramine - ANSWER- Answer: B Ch 50 (#4): A nurse in an outpatient clinic is caring for a client who has a new prescription for an antihypertensive medication. Which of the following instructions should the nurse give to the client? A. "Get up and change positions slowly." B. "Avoid eating aged cheese and smoked meat" C. "Report any unusual bruising and bleeding to the doctor immediately." D. "Eat the same amount of foods that contain vitamin K every day." - ANSWER- A Ch 50 (#5): A nurse in an outpatient medical center is admitting a client for a laparoscopic procedure. The client has a prescription for preoperative diazepam. Prior to administering this medication, which of the following actions is the nurse's priority? A. Teaching the client about the purpose of this medication. B. Giving the medication at the administration time the provider prescribed. C. Identifying the clients medication allergies. D. Documenting the clients anxiety level. - ANSWER- C Ch 51 (#1): To promote adherence to medication self-administration, a nurse is making recommendations for an older adult client. Which of the following instructions should the nurse include? (Select all that apply) A. Adjust dosages according to daily weight. B. Place pills in daily pill holders. C. Ask for liquid form of the client has difficulty swallowing pills. D. Ask a relative to assist periodically. E. Request child-resistant caps on medication containers. - ANSWER- B, C, D Ch 51 (#2): A client in a providers office tells the nurse that "I fast for several days each week to control my weight." The client takes several medications for various chronic issues. The nurse should explain to the client that which of the following mechanisms that results from fasting puts her at risk for medication toxicity? A. Increasing the metabolism of the medication over time. B. Increasing the protein-binding response. C. Increasing the medications' transit time through the intestines. D. Decreasing the excretion of the medications. - ANSWER- B Ch 51 (#3): A nurse is preparing medications for a preschooler. Which of the following factors should the nurse identify as altering how a medication affects children? (Select all that apply) A. Increased gastric acid production B. Immature liver C. Higher body water content D. Increased absorption of topical medications E. Increased gastric emptying time - ANSWER- B, C, D Ch 51 (#4): A nurse is teaching a client who is lactating about taking medications. Which of the following actions should the nurse recommend to minimize in the entry of medication into breast milk? A. Drink 8 oz of milk with each dose of medication. B. Use medications that have an extended half-life. C. Take each dose right after breastfeeding. D. Pump breast milk and freeze it prior to feeding the newborn. - ANSWER- C Ch 51 (#5): A nurse in an outpatient clinic is teaching a client who is in the first trimester of pregnancy. Which of the following statements should the nurse make? A. "You will need to get a rubella immunization if you haven't had one prior to pregnancy." B. "You can safely take OTC medications." C. "You should avoid any vitamin preparations containing iron." D. "Your provider can prescribe a medication for nausea if you need it." - ANSWER- D Ch. 55: A client who had abdominal surgery 24 hr ago suddenly reports a pulling sensation and pain in their surgical incision. The nurse checks the surgical wound and finds it separated with viscera protruding. Which of the following action should the nurse take? (Select all that apply.) A. Cover the area with saline-soaked sterile dressings B. Apply an abdominal binder snugly around the abdomen C. Use sterile gauze to apply gentle pressure to the exposed tissues D. Position the client supine with the hips and knees bent E. Offer the client a warm beverage (herbal tea) - ANSWER- A, D Ch. 56: A nurse is discussing direct and indirect contact modes of transmission of infection at a staff education session. Which of the following incidents should the nurse include as examples of the direct mode of transmission? (Select all that apply.) A. Blood spurting from an arterial wound splashes into a nurse's eye B. A nurse has a needlestick injury C. A mosquito bites a hiker in the woods D. A nurse finds a hole in their glove while handling a soiled dressing E. A person fails to wash their hands after using the bathroom and touches a client - ANSWER- A, E Ch. 56: A nurse in a residential care facility is assessing an older adult client. Which of the following findings should the nurse identify as atypical indications of infection in this client? (Select all that apply.) A. Urinary incontinence B. Malaise C. Acute confusion D. Fever E. Agitation - ANSWER- A, C, E Ch. 56: A nurse is preparing to admit a client who is suspected to have pulmonary tuberculosis. Which of the following actions should the nurse plan to perform first? A. Implement airborne precautions B. Obtain a sputum culture C. Administer antituberculosis medications D. Recommend a screening test for family members - ANSWER- A Ch. 56: A charge nurse is teaching a newly licensed nurse about the care of a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following statements should the charge nurse identify as an indication that the newly licensed nurse understands the teaching? A. "I should obtain a specimen for culture and sensitivity after the first dose of an antimicrobial." B. "MRSA is usually resistant to vancomycin, so another antimicrobial will be prescribed." C. "I will protect others from exposure when I transport the client outside the room." D. "To decrease resistance, antimicrobial therapy is discontinued when the client is no longer febrile." - ANSWER- C Ch. 57: A nurse is performing an admission assessment on a client who has hypovolemia due to vomiting and diarrhea. The nurse should expect which of the following findings? (Select all that apply.) A. Distended neck veins B. Hyperthermia C. Tachycardia D. Syncope E. Decreased skin turgor - ANSWER- C, D, E Ch. 57: A nurse on a medical-surgical unit is caring for a group of clients. The nurse should identify that which of the following clients is at risk for hypovolemia? A. A client who has nasogastric suctioning B. A client who has chronic constipation C. A client who has syndrome of inappropriate antidiuretic hormone D. A client who took a toxic dose of sodium bicarbonate antacids - ANSWER- A Ch. 21 #4 A nurse is talking with the caregivers of a 10-year-old who is concerned that their child is becoming secretive, including closing the door when showering and dressing. Which of the following responses should the nurse make? A. "Perhaps you should try to find out what is happening behind those closed doors." B. "Suggest that the door be left ajar for safety reasons." C. "At this age, children tend to become modest and value their privacy." D. "You should establish a disciplinary plan to stop this behavior." - ANSWER- C School-age children develop a need for privacy. It is important for the caregivers to show trust in the child and respect the child's need for privacy. Ch. 56: A nurse in a primary care clinic is assessing a client who has a history of herpes zoster. Which of the following findings suggests that the client has postherpetic neuralgia. A. Linear clusters of vesicles on the right shoulder B. Purulent drainage from both eyes C. Decreased white blood cell count D. Report of continued pain following resolution of the rash - ANSWER- D Ch. 55: A nurse is caring for a client who is at risk for developing pressure injury. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? (Select all that apply.) A. Keep the head of the bed elevated 30 degrees B. Massage the client's bony prominences frequently C. Apply cornstarch liberally to the skin after bathing D. Have the client sit on a gel cushion when in a chair E. Reposition the client at least every 3 hr while in bed - ANSWER- A, D Ch. 21 #3 A nurse is evaluating teaching about nutrition with the guardians of an 11-year-old child. Which of the following statements should indicate to the nurse an understanding of the teaching? A. "Our child want to eat as much as we do, but we're afraid it will lead to becoming overweight." B. "Our child skips lunch sometimes, but we figure it's okay as long as we eat a healthy breakfast and dinner." C. "We limit fast-food restaurants meals to three times a week now." D. "We reward school achievements with a point system instead of pizza or ice cream." - ANSWER- D Guardians should avoid rewarding children with food for good behavior or achievements. Associations between food and feeling good can lead to weight problems. Ch 48 (#4): A nurse is preparing to administer metoprolol 200 mg PO daily. The amount available is metoprolol 100 mg/tablet. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Do nose use a trailing zero.) - ANSWER- Answer: 2 tablets Ch 48 (#5): A nurse is preparing to administer ketorolac 0.5 mg/kg IV bolus every 6 hr to a school-age child who weighs 66 lb. The amount available is ketorolac injection 30 mg/dL. How many mL should the nurse administer per dose? (Round answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) - ANSWER- Answer: 0.5 mL Ch. 21 #2 A nurse is planning diversionary activities for school-age children on an inpatient pediatric unit. Which of the following activities should the nurse include? (Select all that apply) A. Building models B. Playing video games C. Reading books D. Using toy carpentry tools E. Playing board games - ANSWER- A, B, C, E Ch 48 (#6): A nurse is preparing to administer dextrose 5% in water (D5W) 1,000 mL IV to infuse over 10 hr. The nurse should set the IV infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Do nose use a trailing zero.) - ANSWER- Answer: 100 mL/hr Ch 48 (#7): A nurse is preparing to administer acetaminophen 320 mg PO every 4 hr PRN for pain. The amount available is acetaminophen liquid 160 mg/5 mL. How many mL should the nurse administer per dose? (Round answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) - ANSWER- Answer: 10 mL Ch 48 (#8): A nurse is preparing to administer dextrose 5% in lactated Ringer's (D5LR) 1,000 mL to infuse over 6 hr. The drop factor of he manual IV tubing is 15 gtt/mL. The nurse should adjust the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Do nose use a trailing zero.) - ANSWER- Answer: 42 gtt/min Ch. 7) A nurse is discussing the nursing process with a newly licensed nurse. Which of the following statements by the newly licensed 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 client's record to get more information." C. "I will carryout new prescriptions form the provider." D. "I will ask the client if their nausea has resolved." - ANSWER- A Rationale: prioritize the clients problems during the planning step of the nursing process Ch. 54: A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings. When the nurse pours water into the syringe after the formula drains from the syringe, the client asks the nurse why the water is necessary. Which of the following responses should the nurse make? A. "Water helps clear the tube so it doesn't get clogged." B. "Flushing helps make sure the tube stays in place." C. "This will help you get enough fluids." D. "Adding water makes the formula less concentrated." - ANSWER- A Ch. 7) 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? (SATA) A. Writing a prescription for morphine sulfate as needed for pain B. Inserting an NG tube to relieve gastric distention C. Showing a patient how to use progressive muscle relaxation D. Performing a daily bath after the evening meal E. Repositioning a client every 2 hours to reduce pressure injury risk - ANSWER- C, D, E Rationale: C. Showing a client how to use progressive muscle relaxation is an appropriate nurse-initiated intervention for stress relief. Unless there is a contraindication for a specific client, use this technique with clients without a providers prescription D. Performing a bath is a routine nursing care procedure. Unless there is a contraindication for a specific client, determine when bathing is optimal for a client without a provider's prescription E. Repositioning a client every 2 hours is in appropriate nursing intervention for clients. Unless there is a contraindication for a specific client, use this strategy without a providers prescription Ch. 53: A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take when providing tracheostomy care? (Select all that apply.) A. Apply the oxygen source loosely if the SpO2 decreases during the procedure B. Use surgical asepsis to remove and clean the inner cannula C. Clean the outer cannula surfaces in a circular motion from the stoma site outward D. Replace the tracheostomy ties with new ties E. Cut a slit in gauze squares to place beneath the tube holder - ANSWER- A, B, C Ch. 7) 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? (SATA) A. Respiratory rate is 22/bpm with even, unlabored respirations B. The client's partner states, "they said they hurt after walking about 10 minutes. C. The client's pain rating is 3 on a scale of 0 to 10 D. The client's skin is pink, warm, and dry E. The assistive personnel reports that the client walked with a limp - ANSWER- A, D, E Rationale: Objective data includes information the nurse measures (vital signs), the nurse observes (skin appearance), and observations of others (family and staff) Ch.21 #1 A nurse is talking with caregiver of a 12-year-old child. Which of the following issues verbalized by the caregivers should the nurse identify as the priority? A. "We just don't understand why our child can't keep up with the other kids in simple activities like running and jumping." B. "Our child keeps trying to find ways around our household rules. They always want to make deals with us." C. "We think our child is trying too hard to excel in math just to get the top grades in the class." D. "Our child likes to sing and worries it will make the other kids want to laugh." - ANSWER- A When using the urgent vs. nonurgent approach to client care, the priority issue is the delay in motor skills, which could indicate an illness and requires further investigation. Ch. 53: A nurse is preparing to perform endotracheal suctioning for a client. The nurse should follow which of the following guidelines? (Select all that apply.) A. Apply suction while withdrawing the catheter B. Perform suctioning on a routine basis every 2 to 3 hr C. Maintain medical asepsis during suctioning D. Use a new catheter for each suctioning attempt E. Apply suction for 10 to 15 seconds - ANSWER- A, D, E Ch 47 (#5): A nurse reviewing a client's health record notes a new prescription for lisinopril 10 mg PO once every day. The nurse should identify this as which of the following types of prescriptions? A. Single B. Stat C. Routine D. Now - ANSWER- C. Routine Rationale: A routine or standing prescription identifies medications to give on a regular schedule with or without a termination date or a specific number of doses. Administer this medication every day until the provider discontinues it. Ch 47 (#4): A nurse educator is teaching newly licensed nurses about safe medication administration. Which of the following statements indicates understanding? (Select all that apply) A. "I will observe for adverse effects." B. "I will monitor for therapeutic effects." C. "I will prescribe the appropriate dose." D. "I will change the dose if adverse effects occur." E. "I will refuse to give a medication if I believe it is unsafe." - ANSWER- A, B, E Ch 47 (#3): A nurse orienting a newly licensed nurse is reviewing the procedure for taking a telephone prescription. Which of the following statements should the nurse identify as an indication that the newly licensed nurse understands the process? A. "A second nurse enters the prescription into the client's medical record." B. "Another nurse should listen to the phone call." C. "The provider can clarify the prescription when they sign the health record." D. "I should omit the 'read back' if this is a one-time prescription." - ANSWER- B. Ch 47 (#2): A nurse is reviewing a client's prescribed medications at the beginning of the day shift. Which of the following 0900 medications can be given anytime between 0700 and 1100? (Select all that apply.) A. A once-daily multivitamin B. Eye drops prescribed every 3 hr C. An antibiotic prescribed every 8 hr D. A blood pressure pill prescribed twice daily E. A subcutaneous injection prescribed once weekly - ANSWER- A, E Ch 10: 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 the client to their room. B. Conduct a client care conference. C. Review medical prescriptions. D. Develop a plan of care. - ANSWER- A Ch 46 (#4): A nurse is preparing to inject heparin subcutaneously for a client who is postoperative. Which of the following actions should the nurse take? A. Use a 22-gauge needle. B. Select a site on the client's abdomen C. Use the Z-track technique to displace the skin on the injection site. D. Observe for bleb formation to confirm proper placement. - ANSWER- B. Select a site on the client's abdomen (FYI I saw this as a question on one of the practice exams) Ch 47 (#1): A nurse prepares an injection of morphine to administer to a client who reports pain, then asks a second nurse to give the injection because another assigned client needs to use a bedpan. Which of the following actions should the second nurse take? A. Offer to assist the client who needs the bedpan. B. Administer the injection the other nurse prepared. C. Prepare another syringe and administer the injection. D. Tell the client who needs the bedpan to wait while the nurse gives someone else medication. - ANSWER- A. Ch 46 (#5): A nurse is teaching an adult client how to administer ear drops. Which of the following statements should the nurse identify as an indication that the client understands? A. "I will straighten my ear canal by pulling my ear down and back." B. "I will gently apply pressure with my finger to the front part of my ear (tragus) after putting in the drops." C. "I will insert the nozzle of the ear drop bottle snug into my ear before squeezing the drops in." D. "After the drops are in, I will place a cotton ball all the way into my ear canal." - ANSWER- B. (Also saw this exact question on the practice exam but the answers were worded a little differently) Ch 49 (#5): A nurse is caring for a client receiving dextrose 5% in 0.9% NaCl IV at 120 mL/hr. Which of the following statements by the client should alert the nurse to suspect fluid overload? (Select all that apply.) A. "I feel lightheaded" B. "I feel as though my heart is racing" C. "I feel a little short of breath" D. "The nurse technician told me that my blood pressure was 150/90" E. "I think my ankles are less swollen" - ANSWER- B, C, D Ch 50 (#1) A nurse is collecting data from a client who takes haloperidol to treat schizophrenia. Which of the following findings should the nurse document as extrapyramidal symptoms (EPSs)? (Select all that apply) A. Orthostatic hypotension B. Tremors C. Acute dystonia D. Decreased level of consciousness E. Restlessness - ANSWER- B, C, E Ch. 57: A nurse on a medical-surgical unit is caring for a group of clients. For which of the following clients should the nurse expect a prescription for fluid restriction? A. A client who has a new diagnosis of adrenal insufficiency B. A client who has heart failure C. A client who is receiving treatment for diabetic ketoacidosis D. A client who has abdominal ascites - ANSWER- B Ch. 57: A nurse is planning care for a client who has dehydration. Which of the following actions should the nurse include? A. Administer antihypertensive on schedule B. Check the client's weight each morning C. Notify the provider of a urine output greater than 20 mL/hr D. Encourage independent ambulation four times a day - ANSWER- B Ch. 58: A nurse is planning care for a client who has hypernatremia. Which of the following actions should the nurse include in the plan of care? A. Infuse hypotonic IV fluids B. Implement a fluid restriction C. Increase sodium intake D. Administer sodium polystyrene sulfonate - ANSWER- A Ch. 58: A nurse is reviewing the medical record of a client who has hypocalcemia. The nurse should identify which of the following findings as a risk factor for the development of this electrolyte imbalance? A. Crohn's disease B. Postoperative following appendectomy C. History of bone cancer D. Hyperthyroidism - ANSWER- A Ch. 58: A nurse receives a laboratory report for a client indicating a potassium level of 5.2 mEq/L. When notifying the provider, the nurse should expect which of the following actions? A. Starting an IV infusion of 0.9% sodium chloride B. Consulting with dietitian to increase intake of potassium C. Initiating continuous cardiac monitoring D. Preparing the client for gastric lavage - ANSWER- C Ch. 58: A nurse is collecting data from a client who has hypercalcemia as a result of long-term use of glucocorticoids. Which of the following findings should the nurse expect? (Select all that apply.) A. Hyperreflexia B. Confusion C. Positive Chvostek's sign D. Bone pain E. Nausea and vomiting - ANSWER- B, D, E Ch. 58: A nurse is providing education for a client who has severe hypomagnesemia and is prescribed oral magnesium sulfate. Which of the following information should the nurse include in the teaching? A. "Avoid green, leafy vegetables while taking this medication." B. "You should receive a prescription for a thiazide diuretic to take with the magnesium." C. "You should eliminate whole grains from your diet until your magnesium level increases." D. "Report diarrhea while taking this medication." - ANSWER- D Ch. 21 #5 A nurse is planning a health promotions and primary prevention class for the caregivers of school-age children. Which of the following actions should the nurse plan to take? (Select all that apply.) A. Provide information about the risk of childhood obesity. B. Discuss the danger of substance use disorders. C. Promote discussion about sexual issues. D. Recommend the school-age child sit in the front seat of the car. E. Reinforce stranger awareness. - ANSWER- A, B, C, E Ch. 57: A nurse is reviewing the laboratory test results for a client who has an elevated temperature. The nurse should identify which of the following findings as a manifestation of dehydration? (Select all that apply.) A. Hct 55% B. Blood osmolarity 260 mOsm/kg C. Blood sodium 150 mEq/L D. Urine specific gravity 1.035 E. Blood creatinine 0.6 mg/dL - ANSWER- A, C, D ch11)A nurse is caring for a client who has severe acute respiratory syndrome (SARS). the nurse knows that health care professionals are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting? Select all that apply. a. Planning on devaluating control and prevention strategies b. determining public health priorities c. ensuring proper medical treatment d. identifying endemic disease e. monitoring for common source outbreaks - ANSWER- A,B, C, D,E ch11)A nurse is caring for a client who has had a cough for three weeks and is beginning to cough up blood. The client has manifestations of which of the following conditions? a. Allergic reaction b. ringworm c. systemic lupus erythematous d. tuberculosis - ANSWER- d ch11)a nurse is caring for a client who reports severe sore throat, pain when swallowing, on the swollen lymph nodes. The client is experiencing which of the following stages of infection? a. Prodromal b. incubation c. convalescence d. illness - ANSWER- D ch11)A charge nurse is reviewing with a newly hired nurse the difference in manifestations of a localized versus a systemic infection. 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 - ANSWER- a, b, e ch11)A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following interventions should the nurse include? Select all that apply. a. Place the 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 foot of the 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 gun when performing care that might result in contamination from secretions - ANSWER- B, C, E ch10.) When entering the client 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 foot away from the clients 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 microorganisms into the surgical wound d. keep a box of facial tissues nearby for the client to use during the dressing change - ANSWER- c ch10.) a nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flops 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 - ANSWER- d ch10.) A nurse is reviewing hand hygiene techniques with a group of assistive personnel. Which of the following instructions should the nurse include when discussing handwashing? Select all that apply. a. Apply 3 to 5 milliliters of liquid soap to dry hands b. wash the 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 washing - ANSWER- b, d ch10.) A nurse has prepared a sterile field for assisting a provider with 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 poisons a cotton ball with sterile 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 - ANSWER- b, c, d ch10.) 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 drip 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 - ANSWER- c, d, e CH12.)a nurse discovers a small paper fire in a trash can in a client bathroom. The client has been taken to safety on the alarm has been activated. Which of the following actions should the nurse take? a. Open the windows in the clients room to allow smoke to escape b. obtain a Class C fire extinguisher to extinguish the fire c. remove all electrical equipment from the client room d. place wet towels along the base of the door to the clients room - ANSWER- d CH12.)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 their possession - ANSWER- A CH12.)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 - ANSWER- C CH12.)A nurse manager is reviewing with nurses on the unit in 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 their side b. I will go to the nurses station for assistance c. I will note the time that the seizure begins d. I will prepare to insert an airway - ANSWER- B Ch. 41) A nurse is monitoring a client for adverse effects following the administration of an opioid. Which of the following effects should the nurse identify as an adverse effect of opioids? (SATA) A. Urinary Incontinence B. Diarrhea C. Bradypnea D. Orthostatic hypotension E. Nausea - ANSWER- C, D, E Rationale: adverse effects of opioids are Bradypnea, orthostatic hypotension, nausea AND urinary RETENTION and constipation Ch 41. A nurse