cms quizlet
High-Distinction Exam Materials | Solved Examples, Exam Writing Tips, and Real-
World Practice
"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?
High-Distinction Exam Materials | Solved Examples, Exam Writing Tips, and Real-
World Practice
"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?
