ATI MEDSURG CMS EXAM 2024

"When lifting a heavy object, keep it close to your body." - A nurse is reinforcing teaching about stress injuries. Which of the following instructions should the nurse include? A stage 3 pressure injury on the coccyx - A nurse is providing wound care for a group of clients. Which of the following wounds should the nurse identify as healing by secondary intention? "The living will directs my medical care when I am unable to make decisions." - A nurse is reinforcing teaching with a client about living wills. Which of the following client statements indicates an understanding of the teaching? Urine output of 200 mL over 8 hr - A nurse is collecting data on four clients. Which of the following findings should the nurse report to the provider? Attend an exercise program. - A nurse is using Maslow's hierarchy of needs in assisting with discharge planning for a client. Which of the following activities should the nurse recommend as the priority for this client? The client advances the unaffected leg first while climbing stairs. - A nurse is reinforcing teaching with a client about the use of crutches. Which of the following actions by the client indicates an understanding of the teaching? Provide privacy for the client. - A nurse is preparing to collect data from a client for a health assessment. Which of the following actions should the nurse take? The client reports urinary incontinence. - A nurse is collecting data from an older adult client. Which of the following findings should the nurse report to the provider? The client's face should be turned toward Mecca. - A nurse is caring for a client who has just died and practiced the Islamic faith. Which of the following cultural practices should the nurse expect? Assign the client to a negative-pressure airflow room. - A nurse is assisting with the admission of a client who has active tuberculosis. Which of the following actions should the nurse plan to take? Administer acetaminophen. - A nurse is assisting with the plan of care for a client who has a bacterial infection and a persistent oral temperature of 38.9 degrees C (102 F). Which of the following interventions should the nurse include in the plan of care to treat the fever? Ensure that the client wears a surgical mask during transportation throughout the facility. - A nurse is contributing to the plan of care for a client who has positive throat culture for streptococci. Which of the following interventions should the nurse recommend to be included in the plan of care? Ensure that the client is wearing nonskid slippers is correct. Place the client in a room near the nurses' station is correct Reinforce teaching about how to use the call bell is correct. - A nurse is planning care for a client who is disoriented and at risk for falls. Which of the following interventions should the nurse include? (Select all that apply.) Pad bony prominences on the wrist. - A nurse is contributing to a plan of care for a client who has a new prescription for a wrist restraint. Which of the following actions should the nurse include in the plan? flashing smoke alarm - A nurse is reinforcing teaching with a client who has partial hearing loss about how to modify the home environment. Which of following is a priority modification that the nurse should include? An 18-year-old client who has acute appendicitis - A nurse is caring for four clients who are required to provide informed consent for treatment. The nurse should identify that which of the following clients is able to provide informed consent? BUN 8 mg/dL - A nurse is reviewing the medical record of a client who has heart failure. The nurse should identify which of the following laboratory results as an indication that the client has fluid volume excess? Place feet apart with the foot nearest the head of the client's bed in front of the other foot. - A nurse is moving a client up in bed with the assistance of a second nurse? Which of the following actions should the nurse take? "I will be sure to keep the crutch tips dry." - 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 by the client indicates an understanding of the teaching? Evacuate clients from the area is the first step. Pull the lever on the fire alarm box is second step. Close the fire doors on the unit is the third step. Use a fire extinguisher to put out the fire is the fourth step. - A charge nurse smells smoke, enters the visitor restroom, and sees flames in the trash can. What is the sequence of actions that the 1820 ml - A nurse is calculating the intake and output for a client over the last 8 hr. The client is receiving a continuous IV infusion at 150 ml/hr and had 4 oz of juice and 0.5 L of water. How many mL fluid should the nurse document as the client's intake for the last 8 hr. Beneficence - A nurse is caring for a client who has a prescription for a potassium supplement. The client tells the nurse that the pill is too large to swallow and refuses to take it. The client tells the nurse that the pill is too large to swallow and refuses to take it. The nurse offers to break the pill into two smaller pieces. The nurse is demonstrating which of the following ethical principles? Remove polish from the client's fingernail before applying the oximetry probe. - A charge nurse is reinforcing teaching with an assistive personnel about performing pulse oximetry. Which of the following information should the nurse include in the teaching 1 cup of applesauce - A nurse is reinforcing dietary teaching with a client who has chronic kidney disease and requires a low-potassium diet. Which of the following food choices by the client demonstrates an understanding of the teaching? Nonrebreather mask - A nurse is preparing to administer oxygen to a client who has heart failure and is having severe difficulty breathing. Which of the following oxygen delivery equipment should the nurse select to provide the highest concentration of oxygen to the client? Circulation becomes less efficient with age. - A nurse is assisting with a presentation to a group of older adults at a community center about hypothermia and hyperthermia. Which of the following information should the nurse include about age-related changes? Shred the paper in a secure container. - A nurse is taking notes of client information on a piece of paper while receiving report. Which of the following actions should the nurse take to dispose of the paper? Compare the medications the provider has prescribed with the client's medications from home. - A nurse is assisting with the admission of a client who has brought their medications to the facility. Which of the following actions should the nurse take? Compare the label of the medication container with the medication administration record three times. - A nurse is preparing to administer a topical medication to a client. Which of the following actions should the nurse take? Dorsalis pedis - A nurse is preparing to palpate a client's pulse/ The nurse should recognize that which of the following pulses is located on top of the client's foot? Drain urine from the tubing before ambulation. - 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? Autonomy - A nurse is explaining ethics and values to a newly licensed nurse. The nurse should explain that allowing a client to make a decision about a treatment is an example of which of the following ethical principles? Provide handouts written in the client's primary language. - A nurse is reinforcing preoperative teaching with a client who speaks a different language than the nurse. Which of the following actions should the nurse take? Young adults should receive a dental assessment every 6 months. - A nurse is reinforcing teaching about health promotion with a group of young adult clients. Which of the following information should the nurse include? Document the client's refusal of the treatment. - A nurse is caring for a client who is refusing medical treatment. Which of the following actions should the nurse take? Check the pH of the gastric aspirate. - 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 use to verify correct placement of the NG Tube? Assist a client to get out of bed after a breathing treatment. - A nurse is assisting with the plan of care for four clients. Which of the following tasks should the nurse assign to an assistive personnel? "I see that you are angry. Let's sit down and talk." - A nurse is speaking with a client who has type 2 DM and a prescription for insulin. The client verbalizes anger about having to take insulin. Which of the following responses should the nurse make? Clamp the infusion tubing. - 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? Mild soap - A nurse is caring for a client who has a C. diff infection. Which of the following solutions should the nurse use to perform hand hygiene while caring for this client? Decrease the rate of the feeding. - 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? Compare the client's pedal pulses bilaterally every 4 hr. - 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? "Tell me what the afterlife means to you." - A nurse is caring for a client who has metastatic cancer and practices Catholicism. The client asks the nurse to discuss the afterlife with them. Which of the following statements by the nurse assists in meeting the client's spiritual needs? "This can help prevent pneumonia." - A nurse is reinforcing preoperative teaching with a client about how to turn, cough and deep breathe? Which of the following statements by the clients indicates an understanding of the teaching? "The reduced muscle tone has relaxed the jaw muscles." - A nurse is caring for a client who has a terminal illness and a family member asks why the client's mouth is continually open. Which of the following responses should the nurse make? Administer an analgesic 30 min before starting the procedure. - 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? A client who has a pulse rate of 110/min - A nurse is reviewing the vital signs of four adult clients. Which of the following findings requires further data collection by the nurse? Ask the client close-ended questions. - A nurse is assisting with the plan of care for a client who has aphasia following a stroke. Which of the following interventions should the nurse use to assist the client with communication? Positive Chvostek's sign - 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? Clean soiled areas of the body. - A nurse is assisting with the care of a recently deceased client. Which of the following actions should the nurse complete prior to the family viewing the body? Internally rotate the client's hips by using a trochanter roll. - A nurse is repositioning a client who has quadriplegia and is in the supine position. Which of the following actions should the nurse take to prevent client musculoskeletal injury? Apply thromboembolic stockings. - A nurse is caring for a postoperative client who is at risk for thrombus formation. Which of the following interventions should the nurse delegate to an assistive personnel? Resolved health conditions - A nurse is preparing to transfer a client from an acute care facility to a long-term care facility. Which of the following information should the nurse plan to include in the transfer report? "When I look at myself in the mirror, I don't know if I can go on." - A nurse is caring for a client who has recently undergone a total bilateral mastectomy. Which of the following statements by the client requires immediate action by the nurse? Let the client know that, as their nurse, they are available and willing to listen. - A client who has advanced cancer tells the nurse that they have a difficult time talking to anyone about the illness. Which of the following actions should the nurse take to encourage therapeutic communication? Precontemplation - A nurse is reinforcing teaching with a client about smoking cessation. Which of the following should the nurse identify as the first stage of health behavior change? Cool extremities Orthostatic hypotension Flat neck veins - A nurse is caring for a client who is postoperative and is experiencing nausea and vomiting. The nurse should identify which of the following findings as indications that the client has fluid volume deficit? Speak with the client about their condition after visitors have left. - A nurse at a long term care facility is caring for a client who is alert. Which of the following actions should the nurse take to protect the client's privacy? Donning a mask to measure the vital signs of a client who has pertussis - A nurse has delegated various client care tasks to the assistive personnel on the care team. Which of the following actions by the AP should the nurse identify as correct? "We will keep her room cool to help her breathe better." - A nurse is reinforcing teaching about hospice care measures with the family of a client who is dying. Which of the following statements by a member of the client's family indicates an understanding of the teaching? Pericardial friction rub - 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 place the bladder of the cuff over the posterior aspect of the thigh - 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. Confirm unresponsiveness - 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. Identify the client using to identifiers - 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. Administer analgesics to the child on a routine schedule throughout the day and night - 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. The involvement of the client in planning the change - 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. Obtaining cotton balls for the tracheostomy - 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. Raise the level of the bed - 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. What worries you about being without your teeth? - A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client's dentures be removed prior to surgery. Which of the following responses should the nurse .make? A.It's for your safety. Dentures can slip and block your airway during surgery. B. You wouldn't want your teeth to be lost or broken during surgery, would you? C. The anesthesiologist requires everyone to remove their dentures. D. What worries you about being without your teeth? I keep having nightmares about my upcoming surgery - A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress? A. My parents are retired, and they have come to help out with our children. B. I am going to ask my husband to go to counseling with me. C. I keep having nightmares about my upcoming surgery. D. My girlfriends bought me a nice wig. Obtain client information - A nurse on a medical-surgical unit is caring for a client.Which of the following actions should the nurse take first when using the nursing process? A. Identify goals for client care. B. Obtain client information. C. Document nursing care needs. D. Evaluate the effectiveness of nurse care. Remove the restraints one at a time - A nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints.Which of the following actions should the nurse take while the client is in restraints? A. Tie the restraints to the side rails. B. Perform range-of-motion exercises to the wrists every 3 hrs. C. Remove the restraints one at a time. D. Obtain a PRN prescription for the restraints. Temperature - A nurse is planning care for a client who reports abdominal pain.An assessment by the nurse reveals the client has a temperature of 39.2 (102.6 F), heart rate of 105/min, a soft nontender abdomen, and menses overdue by 2 days.Which of the following findings should be the nurse's priority. A. Heart rate 105/min B. soft, nontender abdomen C. temperature D. overdue menses Carefully remove the gloves and follow with hand hygiene - A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand.The client has no documented bloodstream infection.Which of the following actions should the nurse take? A. Wash the gloved hands and then throw the gloves away. B. Prepare an incident report to document the event. C. Carfefully remove the gloves and follow with hand hygiene. D. Ask the provider to order a blood culture to determine the risk of infection. Absent Val sounds with distention - A nurse is caring for a client who is postoperative and has parlytic ileus.Which of the following abdominal assessments should the nurse expect? A. Frequent bowel sounds with flatus. B. Absent bowel sounds with distention C. Hyperactive bowel sounds with diarrhea. D. Normal bowel sounds with increased peristalsis. Tell me what I can do to help you overcome your fear of giving yourself injections - A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning self-injection of insulin.Which of the following statements should the nurse make? A. "Tell me what I can do to help you overcome your fear of giving yourself injections." B. "I am sure your provider will not be pleased that you refuse to give yourself insulin injections." C. "It's okay. I am sure your partner will be able to learn how to give you the insulin injections." D. "You won't be able to go home unless you learn to give yourself insulin injections." lock the wheels on the bed and stretcher - A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse make to transfer the client from the stretcher to the bed? A. Lock the wheels on the bed and stretcher. B. Instruct the client to raise his arms above his head. C. Elevate the stretcher 2.5cm (1in) above the height of the bed. D. Log roll the client. Sit and hold the clients hand - A nurse is caring for a client who is in the terminal stage of cancer.Which of the following actions should the nurse take when she observes the client crying? A. Contact the family and ask them to stay with the client. B. Offer to call client's minister. C. Sit and hold the client's hand. D. Leave the room and allow the client to cry privately. Grasp a skinfold on chest under clavicle, release, and note whether it's springs back. - A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days.Which of the following actions should the nurse take to assess the client's skin turgor? A. Push on a fingernail bed until it blanches, release it, and observe how long it takes the skin to become pink. B. Grasp a skinfold on chest under clavicle, release, and note whether is springs back. C. Press the skin in above the ankle for 5 seconds, release it, and note the depth of the impression. D. Measure the skin fold thickness at the upper arm using a pair of calbrated skinfold calipers. Encourage the client to express his thoughts about death and dying - A nurse is caring for a client who has terminal illness.The client asks several questions about the nurse's religion beliefs related to death and dying.Which of the following actions should the nurse take? A. Change the topic because the client is trying to divert attention from the illness to the nurse. B. Encourage the client to express his thoughts about death and dying. C. Tell the client that religious beliefs are a personal matter. D. Offer to contact the client's minister or the facility's chaplain. Disconnect the machine, and measure the blood pressure manually every 15 min - A nurse is caring for a client who is unstable and has vital signs measured every 15 min by an electronic blood pressure machine.The nurse notices the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent.Which of the following actions should the nurse take? A. Turn on the machine every 15 min to measure the client's blood pressure. B. Record only blood pressure readings needed for the 15-min intervals. C. Obtain manural and automatic readings and compare them/. D. Disconnect the machine, and measure the blood pressure manually every 15 min. Place a wheelchair at 45° angle to the bed - A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to wheelchair.Which of the following techniques should the nurse use? A. Stand toward the client's stronger side. B. Instruct the client to lean backward from the hips. C. Place the wheelchair at a 45degree angle to the bed. D. Assume a narrow stance with feet 15 cm (6in) apart. Inspection, Auscultation, Palpation, Percussion - Place in order: Inspection Palpation Percussion Auscultation Notify the provider about the clients decision - A nurse is preparing a client who is scheduled for a hysterectomy for transport to the operating room, when the client states she no longer wants to have the surgery.Which of the following actions should the nurse take? A. Tell the client it is too late for her to change her mind because the surgery is already scheduled. B. Telephone the operating room and cancel the surgery. C. Inform the client's family about the situation. D. Notify the provider about the client's decision. The nurse washes her hands held higher than her elbow - A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand-washing technique? A. The nurse washes each part of her hands with 5 strokes. B. The nurse washes from the elbows down to the hands. C. the nurse washes with her hands held higher than her elbows. D. The nurse uses minimal friction when washing her hands. donate autologous blood before the surgery - A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month that might require a blood transfusion.The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following statements should the nurse make to the client? A. "Ask your provider to prescribe epoetin before the surgery." B. "You should ask your provider about taking iron supplements prior to the surgery." C. Request a family member to donate blood for you." D. "Donate autologous blood before the surgery. There are times I should use soap and water rather than an alcohol-based hand rub to clean my hands - A nurse is teaching an assistive personnel (AP) about proper hand hygiene.Which of the following statements by the AP indicates an understanding of the teaching? A. "There are times I should use soap and water rather than an alcohol-based hand rub to clean my hands." B. "I will use cold water when I wash my hands to protect my skin from becoming too dry." C. "I will apply friction for at least 10 seconds while washing my hands." D. "After washing my hands I will dry them from the elbows down." Count the apical pulse rate for one full minute and describe the written in the chart - A nurse is measuring vital signs for a client and notices an irregularity in the pulse.Which of the following actions should the nurse take? A. Measure the pulse using a Doppler ultrasound stethoscope. B. Check the client's pedal pulses. C. Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart. D. Take the pulse at each peripheral site and count the rate for 30 seconds. Using a cuff that is too small will result in an inaccurately high rating - A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular size cuff for a client who is obese. Which of the following explanations should the nurse give the AP? A. "The reading will be inaudible if the cuff is too small for the client." B. "The width of the cuff bladder should be 75% of the circumference of the client's arm." C. As long as the cuff will circle the arm the reading will be accurate. D. "Using a cuff that is too small will result in an inaccurately high reading." The client reports severe - A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who will have emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client? A. The client asks the nurse to repeat the instructions before attempting the exercise. B. The client reports severe pain. C. The client asks the nurse how often deep breathing should be done after surgery. D. The client tells the nurse that this exercise will probably be painful after surgery. Sit on the toilet 30 minutes after eating a meal - A nurse is providing teaching to an older adult client who has constipation.Which of the following statements should the nurse include in the teaching. A. "Drink a min. of 1,000 mL of fluid daily." B. "Increase your intake of refined-fiber foods" C. "Sit on the toilet 30 min after eating a meal. D. "Take a laxative every day to maintain regularity." Temporal - A nurse is planning to obtain the vital signs of a 2 year old child who is experiencing diarrhea and who might have a right ear infection.Which of the following routes should the nurse use to obtain the temperature? A. Rectal B. Tympanic C. Oral D. Temporal Screening groups of older adults and nursing care facilities for early influencer manifestations - A community health nurse is preparing a campaign about seasonal influenza.Which of the following plans should the nurse include as a secondary prevention. A. Holding a community clinic to adminster influenza immunizations. B. Screening groups of older adults in nursing care facilites for early influenza manifestations. C. Educating parents of young children about dangers of influenza. D. Finding rehabilitation programs for older adults who have complications from influenza. elevate pedal pulses - A nurse is admitting a client who has decreased circulation in his left leg.Which of the following actions should the nurse take first? A. Evaluate pedal pulses. B. Obtain a medical history. C. Measure vital signs. D. Assess for leg pain. assessment - A nurse on a medical-surgical unit is admitting a client.Which of the following information should the nurse document in the client's record first? A. Assessment B. Plan of care C. Nursing interventions performed. D. Evaulation of progress. I should expect my heart rate to take longer to return to normal after exercise as I get older - A nurse is teaching a group of older adults about expected changes of aging.Which of the following statements by a group member indicates that the teaching has been effective? A. "I should expect my heart rate to take longer to return to normal after exercise as I get older." B. "Urinary incontinence is something I will have to live with as I grow older." C. "I can expect to have less ear wax as I get older." D. "My stomach will empty more quickly after meals as I grow older." Attempt to increase the clients self motivation - A nurse is planning weight loss strategies for a group of clients who are obese.Which of the following actions by the nurse will improve the client's commitment to a long-term goal of weight loss? A. Attempt to increase the client's self motivation B. Keep detailed records of each client's progress. C. Test client learning after each teaching session. D. Avoid discussing areas that might cause client anxiety. Second intercostal space to the right of the sternum - A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis.At which of the following anatomical areas should the nurse place the stethescope to auscultate the aortic valve? A. Fifth intercostal space just medical to the midclavicular line B. Second intercostal space to the left of the sternum C. Fifth intercostal space to the left of the sternum D. Second intercostal space to the right of the sternum. home health care rehabilitation centers skilled nursing facilities - 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 medicare medicaid - A nurse is explaining the various types of health care coverage clients might have to a group of nursing students. Which of the following healthcare financing mechanisms are 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 Collaborating with providers to perform obesity screenings during routine office visits - 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 healthcare 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 regarding surgical treatments for obesity D. Educating acute care nurses on post operative complications related to obesity Ensuring that healthcare providers comply with regulations - A nurse is discussing the purpose of regulatory agencies during a staff meeting. Which of the following tasks should the nurse identify as a responsibility of state licensing boards? A. Monitoring evidence-based practice for clients who have a specific diagnosis B. Ensuring that healthcare providers comply with regulations C. Setting quality standards for accreditation of healthcare facilities D. Determining if medications are safe for administration to clients intensive care unit oncology treatment center burn center - A nurse is explaining the various levels of healthcare services to a group of newly licensed nurses. Which of the following examples of care or care settings should the nurse classify as tertiary? (Select all that apply) A. Intensive care unit B. Oncology treatment center C. Burn center D. Cardiac rehabilitation E. Home healthcare A client who has terminal cancer requests hospice care in her home A client asks about community resources available for older adults A client requests an electric wheelchair for use after discharge - 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 her home B. A client asks about community resources available for older adults C. A client states that she wants her child baptized before surgery D. A client requests an electric wheelchair for use after discharge E. A client states that he does not understand how to use a nebulizer Occupational therapist - 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 provider pharmacist registered nurse - A client who is postoperative following knee arthroplasty is concerned about the adverse effects of the medication he is receiving for pain management. Which of the following members of the interprofessional care team can assist the client in understanding the medications affects? (Select all that apply) A. Provider B. Certified nursing assistant C. Pharmacist D. Registered nurse E. Respiratory therapist Speech-language pathologist - A client who has had a CVA (cerebrovascular accident) has persistent problems with dysphasia. The nurse caring for the client should initiate a referral with which of the following members of the interprofessional team? A. Social worker B. Certified nursing assistant C. Occupational therapist D. Speech-language pathologist bathing ambulating toileting measuring vital signs - A nurse is equating a group of newly licensed nurses with the roles of the various members of the healthcare team they will encounter on a medical surgical unit. When she gives examples of the types of tasks CNAs may perform which of the following client activities should she include? (Select all that apply) A. Bathing B. Ambulating C. Toileting D. Determining pain level E. Measuring vital signs autonomy - A nurse is caring for a client who decides not to have surgery despite significant blockages in his coronary arteries. The nurse understands that this clients choice is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence D. Beneficence - 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 justice - A nurse is instructing a group of nursing students 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 nurse should understand that this aspect of care delivery is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence Nonmaleficence - A nurse questions a medication prescription as too extreme in light of the clients 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 A family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill - A nurse is instructing a group of nursing students about how to know and what to expect when ethical dilemmas arise. Which of the following situations should the students identify as an ethical dilemma? A. A nurse on a medical surgical unit demonstrate signs of chemical impairment. B. A nurse overhears another nurse telling an older adult client that if he doesn't 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 her spouse on her durable power of attorney form. assault - A nurse observes an AP reprimanding a client for not using the urinal properly. The AP tells him she will put a diaper on him if he does not use the urinal more carefully next time. Which of the following torts is the AP committing? A. Assault B. Battery C. False imprisonment D. Invasion of privacy False imprisonment - A nurse is caring for a competent adult client who tells the nurse that he's thinking about leaving the hospital against medical advice. The nurse believes that this is not in the clients best interest, so she prepares to administer a PRN sedative medication the client has not requested along with his usual 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 I plan to write that I don't want them to keep me on a breathing machine. - 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 he will prepare his advance directives before he goes 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. Make sure the surgeon obtained the clients consent Witness the client signature on the consent form - 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 clients consent B. Witness the client 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 Report the observations to the nurse manager on the unit - A nurse has noticed several occasions in the past week on another nurse on the unit seem drowsy and unable to focus on the issue at hand. Today, she found the nurses sleep in a chair in the break room when she was not on a break. Which of the following actions should the nurse take? A. Alert the ANA B. Fill out an incident report C. Report the observations to the nurse manager on the unit D. Leave the nurse alone to sleep Bone scan scheduled for today - 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 Family members should provide a code prior to receiving client health information Communication of client information can occur at the nurses station. A client can request a copy of her medical record A nurse my photo copy a clients medical record for transferred to another facility - A nurse is discussing the HIPAA Privacy rule with nurses during new employee orientation. Which of the following information should the nurse 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 her medical record E. A nurse my photo copy a clients medical record for transferred to another facility Put the date and time on all entries Document objective data leaving out opinions - A nurse is reviewing documentation with a group of newly licensed nurses. Which of the following legal guidelines should be followed when documenting in a clients 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 medication error needle sticks omission of prescription - 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? (Select all that apply) A. Medication error B. Needle sticks C. Conflict with provider and nursing staff D. Omission of prescription E. Missed specimen collection of a prescribe laboratory test Repeat the details of the prescription back to the provider Have another nurse listen to the telephone prescription Obtain providers signature on the prescription within 24 hours - A nurse is receiving a providers prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? (Select all that apply) A. Repeat the details of the prescription back to the provider B. Have another nurse listen to the telephone prescription C. Obtain providers signature on the prescription within 24 hours D. Decline the verbal prescription because it is not an emergency situation E. Tell the charge nurse that the provider has prescribed morphine by telephone. Reapplying a condom catheter for a client who has urinary incontinence - A nurse on a medical surgical unit has received change of shift report and will care for four clients. Which of the following clients needs should the nurse assigned to an AP? A. Updating the plan of care for a client who is post operative B. Reinforcing teaching with a client who is learning to walk using a quad C. Reapplying a condom catheter for a client who has urinary incontinence D. Applying a sterile dressing to a pressure ulcer the client has tenderness and warmth in their calf. - A nurse is collecting data from a client who is 1 day postoperative following abdominal surgery. Which of the following findings is the priority for the nurse to report to the provider? Choose a private room for the interview - A nurse in a long-term care facility is collecting admission data from a client who uses a hearing aid. Which of the following actions should the nurse take Keep the family updated about the client's status is correct. Encourage the family to comb the client's hair is correct. Tell the client's family what to expect as the client's death nears is correct. - A nurse is contributing to the plan of care for a client who is dying. Which of the following interventions should the nurse recommend to include the client's family in the plan of care? (Select all that apply.) A piston syringe - A nurse is preparing to perform a wound irrigation for a client who has a stage 3 pressure injury. Which of the following supplies should the nurse plan to use? Attach a humidifier to the base of the flow meter. - A nurse is caring for a client who has a new prescription for oxygen at 7 L/min via simple face mask. Which of the following actions should the nurse take to ensure client safety? Pallor with scaly skin - A nurse is assisting with the admission of a client to a medical-surgical unit. Which of the following findings should the nurse identify as an indication that the client is malnourished? "I will remove all stuffed animals from my baby's crib." - A nurse is reinforcing teaching with a new parent who is concerned about sudden infant death syndrome (SIDS). Which of the following statements by the client indicates an understanding of the teaching? Instruct the client to tilt their head forward while eating. - A nurse is caring for a client who has dysphagia following a stroke. Which of the following interventions should the nurse use when feeding the client? Perform a bladder scan. - A nurse is planning to perform intermittent urinary catheterization for a client who is unable to urinate. Which of the following actions should the nurse take first? "You should cover your mouth with a tissue when you cough." - A nurse is reinforcing teaching with a client who has pneumonia and a productive cough. Which of the following instructions should the nurse include in the teaching Support the client's feet with foot boots. - A nurse is contributing to the plan of care for a client who is at risk for developing foot drop due to immobility. Which of the following interventions should the nurse recommend to include in the plan? Client states, "I started to itch after taking that medication." - A nurse is caring for a client who reports itching 30 min after receiving a newly prescribed medication. Which of the following data should the nurse document in the client's medical record? A client who has measles - A nurse is contributing to the plan of care for four clients. For which of the following clients should the nurse initiate airborne precautions? RN - A nurse manager of a medical surgical unit is assigning care responsibilities for the oncoming shift. A client is awaiting transfer back to the unit from the PACU following thoracic surgery. To which of the following staff members should the nurse assigned the client? A. Charge nurse B. RN C. Practical nurse (PN) D. Assistive personnel (AP) The client ambulates with his slippers on over his antiembolic stockings. The client uses a front-wheeled walker when ambulating The client had pain medication 30 minutes ago - A nurse is delegating the ambulation of a client who had knee arthroplasty five days ago to an AP. Which of the following information should the nurse share with the AP? (Select all that apply) A. The roommate ambulates independently B. The client ambulates with his slippers on over his antiembolic stockings. C. The client uses a front-wheeled walker when ambulating D. The client had pain medication 30 minutes ago Teaching a client who has asthma to use a metered dose inhaler - An RN is making assignments for a PN at the beginning of the shift which of the following assignments should the PN question? A. Assisting a client who is 24 hour post operative to use an incentive spirometer B. Collecting a clean catch urine specimen from a client who has a wound infection C. Providing nasopharyngeal suctioning for a client who has pneumonia D. Teaching a client who has asthma to use a metered dose inhaler Right supervision and evaluation Right direction and communication Right circumstances - A nurse is preparing an in-service program about delegation. Which of the following elements should she identify when presenting the five rights of delegation? (Select all that apply) A. Right client B. Right supervision and evaluation C. Right direction and communication D. Right time E. Right circumstances Reassess the client to determine the reasons for an adequate pain relief - 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 an adequate pain relief B. Wait to see whether the pain lessons during the next 24 hours 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. Respiratory rate is 22/min with even, unlabored respirations. Skin is pink, warm, and dry The AP reports the client walked with a limp - 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? (Select all that apply) A. Respiratory rate is 22/min with even, unlabored respirations. B. The clients partner states, "he said he hurts after walking about 10 minutes." C. Pain rating is three on a scale of 0 to 10 D. Skin is pink, warm, and dry E. The AP reports the client walked with a limp Showing a client how to use progressive muscle relaxation Performing a daily bath after the evening meal Re-positioning a client every two hours to reduce pressure ulcer risk. - A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a providers prescription. Which of the following interventions should the charge nurse include? (Select all that apply) A. Writing a prescription for morphine sulfate as needed for pain B. Inserting a nasogastric (NG tube) to relieve gastric distention C. Showing a client how to use progressive muscle relaxation D. Performing a daily bath after the evening meal E. Re-positioning a client every two hours to reduce pressure ulcer risk. I will determine the most important client problems that we should address - A nurse is discussing the nursing process with a newly hired nurse. Which of the following statements by the newly hired 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 clients record to get more information C. I will go carry out the new prescriptions from the provider D. I will ask the client if his nausea has resolved