Fundamentals
CMS
Midterm
A
nurse
is
assessing
the
heart
sounds
of
a
client
who
has
developed
chest
pain
that
becomes
worse
with
inspiration.
The
nurse
auscultates
a
high-pitched
scratching
sound
during
both
systole
and
diastole
with
the
diaphragm
of
the
stethoscope
positioned
at
the
left
sternal
border.
Which
of
the
following
heart
sounds
should
the
nurse
document?
A.
Audible
Click
B.
Murmur
C.
Third
heart
sound
D.
Pericardial
friction
rub
-
ANS
D)
Pericardial
friction
rub
A
nurse
is
obtaining
the
blood
pressure
in
a
client's
lower
extremity.
Which
of
the
following
action
should
the
nurse
take?
A.
Auscultate
for
the
blood
presure
at
the
dorsalis
pedis
artery.
B.
Measure
the
blood
pressure
with
the
client
sitting
on
the
side
of
the
bed.
C.
Place
the
cuff
7.6cm
(3in)
above
the
popliteal
artery.
D.
Place
the
bladder
of
the
cuff
over
the
posterior
aspect
of
the
thigh.
-
ANS
D)
place
the
bladder
of
the
cuff
over
the
posterior
aspect
of
the
thigh A
charge
nurse
is
teaching
adult
cardiopulmonary
resusciation
(CPR)
to
a
group
of
newly
licensed
nurses.
Which
of
the
following
actions
should
the
charge
nurse
teach
as
the
first
response
in
CPR?
A.
Call
for
assisstance
B.
Begin
Chest
compressions
C.
Confirm
unresponsiveness.
D.
Give
rescue
breaths.
-
ANS
C)
Confirm
unresponsiveness
A
nurse
is
caring
for
a
client
who
requires
a
chest
x-ray.
Prior
to
the
client
being
transported
for
the
procedure,
which
of
the
following
actions
should
the
nurse
take
first?
A.
Explain
the
x-ray
procedure
to
the
client.
B.
Help
the
client
into
a
wheelchair
before
the
transporter
arrives.
C.
Ask
if
the
client
has
any
questions.
D.
Identify
the
client
using
two
identifiers.
-
ANS
D)
Identify
the
client
using
to
identifiers
A
nurse
is
caring
for
a
child
who
is
postoperative
following
a
tonsillectomy.
Which
of
the
following
actions
should
the
nurse
take?
A.
Encourage
the
child
to
cough
frequently
to
clear
congestion
from
anesthesia. B.
Place
a
heating
pad
at
the
child's
neck
for
comfort.
C.
Administer
analgesics
to
the
child
on
a
routine
schedule
throughout
the
day
and
night.
D.
Provide
the
child
with
ice
cream
when
oral
intake
is
initiated.
-
ANS
C)
Administer
analgesics
to
the
child
on
a
routine
schedule
throughout
the
day
and
night
A
nurse
is
providing
teaching
to
a
client
who
has
heart
failure
about
how
to
reduce
his
daily
intake
of
sodium.
Which
of
the
following
factors
is
the
most
important
in
determining
the
client's
ability
to
learn
new
dietary
habits?
A.
The
involvement
of
the
client
in
planning
the
change.
B.
The
emphasis
the
provider
places
on
the
dietary
changes.
C.
The
learning
theory
the
nurse
uses
to
teach
the
dietary
changes.
D.
The
extent
of
the
dietary
changes
planned
for
the
client.
-
ANS
A)
The
involvement
of
the
client
in
planning
the
change
A
charge
nurse
is
observing
a
newly
licensed
nurse
perform
tracheostomy
care
for
a
client.
Which
of
the
following
actions
by
the
newly
licensed
nurse
requires
intervention?
A.
Obtaining
hydrogen
peroxide
for
the
trachesotomy
care. B.
Obtainging
cotton
balls
for
the
tracheostomy
care.
C.
Obtaining
sterile
gloves
for
the
tracheostomy
care.
D.
Obtaining
a
sterile
brush
for
the
tracheostomy
care.
-
ANS
B)
Obtaining
cotton
balls
for
the
tracheostomy
A
nurse
is
preparing
to
perform
mouth
care
for
an
unresponsive
client.
Which
of
the
following
actions
should
the
nurse
plan
to
take?
A.
Place
the
client
supine.
B.
Keep
both
side
rails
up.
C.
Raise
the
level
of
the
bed.
D.
Inspect
the
client's
mouth
using
a
finger
sweep.
-
ANS
C)
Raise
the
level
of
the
bed
A
nurse
is
witnessing
a
client
sign
an
informed
consent
form
for
surgery.
Which
of
the
following
describes
what
the
nurse
is
affirming
by
this
action?
A.
The
client
fully
understands
the
provider's
explannation
of
the
procedure.
B.
The
client
has
been
informed
about
the
risks
and
benefits
of
the
procedure.
C.
The
nurse
witnessed
the
provider's
explanantion
of
the
procedure.
D.
The
signature
on
the
preoperative
consent
form
is
the
client's.
-
ANS
D)
The
signature
on
the
pre-operative
consent
form
is
the
clients
CMS
Midterm
A
nurse
is
assessing
the
heart
sounds
of
a
client
who
has
developed
chest
pain
that
becomes
worse
with
inspiration.
The
nurse
auscultates
a
high-pitched
scratching
sound
during
both
systole
and
diastole
with
the
diaphragm
of
the
stethoscope
positioned
at
the
left
sternal
border.
Which
of
the
following
heart
sounds
should
the
nurse
document?
A.
Audible
Click
B.
Murmur
C.
Third
heart
sound
D.
Pericardial
friction
rub
-
ANS
D)
Pericardial
friction
rub
A
nurse
is
obtaining
the
blood
pressure
in
a
client's
lower
extremity.
Which
of
the
following
action
should
the
nurse
take?
A.
Auscultate
for
the
blood
presure
at
the
dorsalis
pedis
artery.
B.
Measure
the
blood
pressure
with
the
client
sitting
on
the
side
of
the
bed.
C.
Place
the
cuff
7.6cm
(3in)
above
the
popliteal
artery.
D.
Place
the
bladder
of
the
cuff
over
the
posterior
aspect
of
the
thigh.
-
ANS
D)
place
the
bladder
of
the
cuff
over
the
posterior
aspect
of
the
thigh A
charge
nurse
is
teaching
adult
cardiopulmonary
resusciation
(CPR)
to
a
group
of
newly
licensed
nurses.
Which
of
the
following
actions
should
the
charge
nurse
teach
as
the
first
response
in
CPR?
A.
Call
for
assisstance
B.
Begin
Chest
compressions
C.
Confirm
unresponsiveness.
D.
Give
rescue
breaths.
-
ANS
C)
Confirm
unresponsiveness
A
nurse
is
caring
for
a
client
who
requires
a
chest
x-ray.
Prior
to
the
client
being
transported
for
the
procedure,
which
of
the
following
actions
should
the
nurse
take
first?
A.
Explain
the
x-ray
procedure
to
the
client.
B.
Help
the
client
into
a
wheelchair
before
the
transporter
arrives.
C.
Ask
if
the
client
has
any
questions.
D.
Identify
the
client
using
two
identifiers.
-
ANS
D)
Identify
the
client
using
to
identifiers
A
nurse
is
caring
for
a
child
who
is
postoperative
following
a
tonsillectomy.
Which
of
the
following
actions
should
the
nurse
take?
A.
Encourage
the
child
to
cough
frequently
to
clear
congestion
from
anesthesia. B.
Place
a
heating
pad
at
the
child's
neck
for
comfort.
C.
Administer
analgesics
to
the
child
on
a
routine
schedule
throughout
the
day
and
night.
D.
Provide
the
child
with
ice
cream
when
oral
intake
is
initiated.
-
ANS
C)
Administer
analgesics
to
the
child
on
a
routine
schedule
throughout
the
day
and
night
A
nurse
is
providing
teaching
to
a
client
who
has
heart
failure
about
how
to
reduce
his
daily
intake
of
sodium.
Which
of
the
following
factors
is
the
most
important
in
determining
the
client's
ability
to
learn
new
dietary
habits?
A.
The
involvement
of
the
client
in
planning
the
change.
B.
The
emphasis
the
provider
places
on
the
dietary
changes.
C.
The
learning
theory
the
nurse
uses
to
teach
the
dietary
changes.
D.
The
extent
of
the
dietary
changes
planned
for
the
client.
-
ANS
A)
The
involvement
of
the
client
in
planning
the
change
A
charge
nurse
is
observing
a
newly
licensed
nurse
perform
tracheostomy
care
for
a
client.
Which
of
the
following
actions
by
the
newly
licensed
nurse
requires
intervention?
A.
Obtaining
hydrogen
peroxide
for
the
trachesotomy
care. B.
Obtainging
cotton
balls
for
the
tracheostomy
care.
C.
Obtaining
sterile
gloves
for
the
tracheostomy
care.
D.
Obtaining
a
sterile
brush
for
the
tracheostomy
care.
-
ANS
B)
Obtaining
cotton
balls
for
the
tracheostomy
A
nurse
is
preparing
to
perform
mouth
care
for
an
unresponsive
client.
Which
of
the
following
actions
should
the
nurse
plan
to
take?
A.
Place
the
client
supine.
B.
Keep
both
side
rails
up.
C.
Raise
the
level
of
the
bed.
D.
Inspect
the
client's
mouth
using
a
finger
sweep.
-
ANS
C)
Raise
the
level
of
the
bed
A
nurse
is
witnessing
a
client
sign
an
informed
consent
form
for
surgery.
Which
of
the
following
describes
what
the
nurse
is
affirming
by
this
action?
A.
The
client
fully
understands
the
provider's
explannation
of
the
procedure.
B.
The
client
has
been
informed
about
the
risks
and
benefits
of
the
procedure.
C.
The
nurse
witnessed
the
provider's
explanantion
of
the
procedure.
D.
The
signature
on
the
preoperative
consent
form
is
the
client's.
-
ANS
D)
The
signature
on
the
pre-operative
consent
form
is
the
clients
