CMS Fundamentals Exam with 100% verified solutions-

CMS Fundamentals Exam with 100% verified solutions- A nurse administers subcutaneous lispro insulin at 0700 to a client who has diabetes. At which of the following times should the nurse observe for hypoglycemia caused by the onset of the medication? 0715 What is required by medical asepsis that is not required by surgical asepsis? good hand washing technique A nurse is preparing to administer dexamethasone 1.5 mg/kg/day PO to divide equally every 6 hours to a preschool-age child who weighs 22 lb. Available is dexamethasone oral solution 1 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth.) 3.8 A postoperative client who has no previous medical conditions is difficult to arouse when transferred to the surgical unit from the post-anesthesia care unit. A nurse monitors the pulse oximeter and gets a reading of 85%. The nurse arouses the client and has him cough and perform deep breathing; the pulse oximeter is now reading 83% what should be the nurse's next action? Start oxygen at 2 liters per nasal cannula. A nurse in the emergency department knows that tissue damage has probably occurred in a person with hypothermia when a rectal temperature of is assessed. (do not use degree sign,) 95 At 0330, a nurse is caring for a client who is postoperative. The client's IV fluids are infusing at 120 mL/hr. How many mL of IV fluid should infuse by 0600? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) 300 A nurse is reinforcing teaching with a client who has a family history of hypertension. The nurse should inform the client that his blood pressure reading of 112/64 mm Hg places him in which of the following categories? Within the expected reference range A nurse is reinforcing teaching with a client who has type 2 diabetes mellitus. The nurse determines that teaching has been effective when the client identifies which of the following manifestations of hypoglycemia? (Select all that apply.) -Blurry vision -tachycardia -sweating A nurse is reinforcing teaching with a client who has diabetes mellitus and self-administers insulin. The client reports drinking an occasional glass of wine. Which of the following is an appropriate response by the nurse? "It is best for you to drink an occasional glass of wine with a meal". A nurse is caring for a client who has type 1 diabetes mellitus. The nurse misread the client's morning fasting blood glucose level as 210 mg/dL instead of 120 mg/dL and administered the insulin dose appropriate for a reading over 200 mg/dL. Which of the following actions should the nurse identify as the priority? Check the client's blood glucose level. A nurse is assisting with the plan of care for a client who has a new deep-vein thrombosis (DVT) in his leg. Which of the following interventions should the nurse include in the plan? Keep the clients affected leg elevated A nurse is collecting data from a client who is postoperative following abdominal surgery. Which of the following findings should cause the nurse to suspect deep-vein thrombosis (DVT)? unilateral leg edema A nurse is collecting data from a client who has hypertension and a prescription for propranolol. A history of which of the following conditions should be reported to the provider? Heart failure A nurse is caring for an older adult client who has colon cancer. The client asks the nurse several questions about his treatment plan. Which of the following actions should the nurse take? Help the client write down questions to ask his provider. A nurse is collecting data from client who has received chemotherapy to treat lung cancer. Which of the following adverse effects should the nurse report to the provider? Manifestations of infection. A nurse is assisting with the plan of care for a client who has pneumonia and requires chest percussion, vibration, and postural drainage. Which of the following actions should the nurse plan to complete first? Auscultate lung fields A nurse is collecting data from a client who has pneumonia and is experiencing acute respiratory acidosis. Which of the following manifestations should the nurse expect to find? Decreased level of consciousness A nurse is caring for a client who is postoperative open reduction and internal fixation with placement of a wound drain to repair a hip fracture. Which of the following actions should the nurse take? Empty the suction device every 4 hours. A nurse is reinforcing teaching with an older adult client who has had a newly inserted permanent pacemaker. Which of the following manifestations should the nurse include in the teaching as a pacemaker malfunction that the client should report to the provider? Fatigue A nurse is caring for a client who has just been diagnosed with angina pectoris. The client tells the nurse that he is afraid of dying from a heart attack. Which of the following is an appropriate nursing response? "Tell me more about these fears". A nurse is assisting with the care of a client who was admitted to the emergency department with reports of chest pain and severe epigastric distress. The nurse should anticipate that in the presence of an acute myocardial infarction the client's creatinine kinase-MB (CK-MB) is expected to peak how many hours after the onset of chest pain? 24 hours A nurse is assisting in the plan of care for a client who has a suspected myocardial infarction. Which of the following medication should the nurse plan to administer first? Oxygen A nurse is caring for a client who has heart failure and respiratory arrest. Which of the following actions should the nurse take first? Feel for a carotid pulse A nurse is caring for a client who is receiving furosemide to treat heart failure. Which of the following laboratory values should the nurse monitor for this client? Serum potassium A nurse is reinforcing teaching with a client who has HIV and is being discharged to home. Which of the following instructions should the nurse include in the teaching? Take temperature once a day A nurse is reviewing a recent laboratory report for a client who has Human Immunodeficiency Virus (HIV). Which of the following laboratory values should the nurse report to the provider? CD4-T-Cell count 140/mm3 A nurse is caring for a client who has partial-thickness and full-thickness burns of his head, neck, and chest. The nurse should recognize which of the following is the priority risk to the client? Airway obstruction A nurse is caring for a client who has metabolic alkalosis. For which of the following clinical manifestations should the nurse monitor? (Select all that apply.) -Shallow respirations -cardiac dysthymias -hyperactive reflexes A nurse is reviewing the laboratory results of a client who is postoperative and has a respiratory rate of 7/min. The arterial blood gas (ABG) values include: pH 7.22 PaCO2 68 mm Hg Base excess -2 PaO2 78 mm Hg Oxygen saturation 80% Bicarbonate 28 mEq/L Which of the following interpretations of the ABG values should the nurse make? Respiratory acidosis A nurse is collecting data from a client whose arterial blood gas values reveal a pH of 7.24, PaCO2 of 53, and an HCO3- of 24. The nurse should prepare to treat the client for which of the following acid- base imbalances? respiratory acidosis A nurse is reinforcing discharge teaching with a client following an episode of status asthmaticus. The client has a prescription for two inhalations from an albuterol metered-dose inhaler. Which of the following statements by the client indicates an understanding of the teaching? "I will hold my breath at least 10 seconds after inhaling the medication". A nurse is reinforcing teaching about rifampin with a female client who has active tuberculosis. Which of the following statements should the nurse include in the teaching? "You need to use alternative methods of birth control besides oral contraceptives". A nurse is reinforcing teaching for a client about carbon monoxide poisoning. Which of the following statements should the nurse identify as an indication that the client needs further teaching? "I can detect the presence of carbon monoxide by its metallic odor." A nurse is measuring the vital signs of a client he suspects has hypovolemic shock. Which of the following findings should the nurse expect? Low BP, high pulse rate. A nurse is assisting with the care of a client who has septic shock and is at risk for disseminated intravascular coagulation (DIC). Which of the following nursing statements indicates an understanding of the condition? DIC is caused by abnormal coagulation involving fibrinogen A nurse is monitoring a client for complications of immobility. Which of the following findings should the nurse expect? (Select all that apply.) Contractures of extremities Crackles in the lungs. Pressure ulcers. A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions is the priority for the nurse to take? Begin oxygen therapy A nurse is reinforcing discharge teaching with a client who has asthma and a new prescription for salmeterol. Which of the following instructions should the nurse include? "This medication will provide long-term control of your asthma symptoms." A nurse is caring for a client who has COPD. Which of the following actions should the nurse take? Encourage the client to drink 8 glasses of water a day.