CDM FINAL EXAM NCLEX Correctly answered
Questions Revised and Graded Excellent
A client had a recent fall and has residual dizziness. What action by the nurse best promotes
safety for the client during dressing?
Have the client sit for as much dressing as possible.
Perform the majority of dressing for the client.
Teach the client to hold the bed with one hand.
Use a gait belt in case the patient falls during dressing. - CORRECT ANSWER ✔✔ -Have the
client sit for as much dressing as possible- For safety, a patient with dizziness and a history of
falls should sit for as much of dressing as possible as this activity can be tiring. Using a gait belt
does help prevent falls, but sitting is a better option. Holding the bed with one hand limits the
amount of self-dressing the client can do. The nurse performing most of the dressing does not
help the client gain or maintain independence.
A client has a core temperature of 32.2° C (90° F). Which action by the nursing student requires
the registered nurse to intervene?
Removes wet, cold clothing
Places blankets on client's head
,Obtains a forced-air warming blanket
Gives the client warm beverages - CORRECT ANSWER ✔✔ -Obtains a forced-air warming
blanket-A forced-air warming blanket is appropriate for moderate hypothermia (28° C to 32.1° C
[82.4° F to 90° F]). The other actions are appropriate for this client with mild hypothermia. Mild
hypothermia is treated by allowing the client's own body to generate heat and warm itself
passively.
A client has been on bed rest for several weeks and now has orders to begin increasing activity as
tolerated. The client is concerned about tolerating more activity. Which action by the nurse is
best?
Teach the client about the benefits of increased activity.
Assist the client in setting realistic short term activity goals.
Discuss all the potential complications of remaining bedfast.
Call the provider and request a physical therapy consultation. - CORRECT ANSWER ✔✔ -
Assist the client in setting realistic short term activity goals.-Clients who have helped set goals
are more likely to participate in activities that help reach that goal. For a client who is
apprehensive about increasing activity, mutually agreeing on short term goals could help
encourage the client to try the activities. Teaching the client about the benefits of activity and
about the complications of immobility are certainly important, but may not convince a client to
participate. A physical therapy consultation is not indicated in this situation.
,A client has fluid volume deficit and the provider has prescribed isotonic IV solution at a rate of
100 ml/hour. Which solution does the nurse choose?
0.9% sodium chloride (NS)
0.45% sodium chloride (1/2 NS)
5% dextrose in water (D5W)
10% dextrose in water (D10W) - CORRECT ANSWER ✔✔ -0.9% sodium chloride (NS)- 0.9%
sodium chloride is the only isotonic solution listed. 0.45% NS and D5W are hyptotonic. D5W is
often listed as isotonic, but when infusing, the dextrose is metabolized so quickly that in essence
it is hypotonic. D10W is hypertonic.
A client has suffered an out-of-hospital cardiac arrest. The nurse prepares to institute therapeutic
hypothermia. What action by the nurse is inconsistent with this treatment modality?
Using two methods of temperature monitoring
Providing care with a ventilator bundle
Allowing shivering only during rewarming
Implementing pressure sore prevention methods - CORRECT ANSWER ✔✔ -Allowing
shivering only during rewarming-Shivering should not be allowed during therapeutic
hypothermia as is increases metabolic rate (and oxygen consumption) and causes coagulopathies.
Sedative are used to control shivering. The other actions are appropriate.
, A client is admitted with end-stage cancer and has several medications ordered for pain control,
including long-acting narcotics, non-narcotic pain medications, and medications for
breakthrough pain. The client complains loudly of pain of 2 on a 1-10 scale and is angry that the
pain cannot be controlled. Which intervention by the nurse is best?
Administer the medication for breakthrough pain.
Ask the client to explain more about the pain.
Inform the provider that the client needs more medication.
Teach the client how different pain medications work. - CORRECT ANSWER ✔✔ -Ask the
client to explain more about the pain.- The first step in the nursing process and the first step in
achieving pain control is assessment. There appears to be more occurring with this client that
simple pain control. In order to perform a holistic assessment, the nurse should listen
empathetically and have the client describe the current experience. After gathering date, the
nurse and client can work collaboratively to develop a pain management plan. The nurse realizes
that comfort is a holistic state under which pain management is achieved. The other options do
not include a holistic assessment but rather are reactive.
A client is given a new prescription for opioid pain medication to treat chronic pain and is also
given prescriptions for a stool softener and stimulant laxative. The client only wants to fill the
pain medication prescription. What response by the nurse is best?
"Well wait and see if you have constipation, then fill them if you do."
Questions Revised and Graded Excellent
A client had a recent fall and has residual dizziness. What action by the nurse best promotes
safety for the client during dressing?
Have the client sit for as much dressing as possible.
Perform the majority of dressing for the client.
Teach the client to hold the bed with one hand.
Use a gait belt in case the patient falls during dressing. - CORRECT ANSWER ✔✔ -Have the
client sit for as much dressing as possible- For safety, a patient with dizziness and a history of
falls should sit for as much of dressing as possible as this activity can be tiring. Using a gait belt
does help prevent falls, but sitting is a better option. Holding the bed with one hand limits the
amount of self-dressing the client can do. The nurse performing most of the dressing does not
help the client gain or maintain independence.
A client has a core temperature of 32.2° C (90° F). Which action by the nursing student requires
the registered nurse to intervene?
Removes wet, cold clothing
Places blankets on client's head
,Obtains a forced-air warming blanket
Gives the client warm beverages - CORRECT ANSWER ✔✔ -Obtains a forced-air warming
blanket-A forced-air warming blanket is appropriate for moderate hypothermia (28° C to 32.1° C
[82.4° F to 90° F]). The other actions are appropriate for this client with mild hypothermia. Mild
hypothermia is treated by allowing the client's own body to generate heat and warm itself
passively.
A client has been on bed rest for several weeks and now has orders to begin increasing activity as
tolerated. The client is concerned about tolerating more activity. Which action by the nurse is
best?
Teach the client about the benefits of increased activity.
Assist the client in setting realistic short term activity goals.
Discuss all the potential complications of remaining bedfast.
Call the provider and request a physical therapy consultation. - CORRECT ANSWER ✔✔ -
Assist the client in setting realistic short term activity goals.-Clients who have helped set goals
are more likely to participate in activities that help reach that goal. For a client who is
apprehensive about increasing activity, mutually agreeing on short term goals could help
encourage the client to try the activities. Teaching the client about the benefits of activity and
about the complications of immobility are certainly important, but may not convince a client to
participate. A physical therapy consultation is not indicated in this situation.
,A client has fluid volume deficit and the provider has prescribed isotonic IV solution at a rate of
100 ml/hour. Which solution does the nurse choose?
0.9% sodium chloride (NS)
0.45% sodium chloride (1/2 NS)
5% dextrose in water (D5W)
10% dextrose in water (D10W) - CORRECT ANSWER ✔✔ -0.9% sodium chloride (NS)- 0.9%
sodium chloride is the only isotonic solution listed. 0.45% NS and D5W are hyptotonic. D5W is
often listed as isotonic, but when infusing, the dextrose is metabolized so quickly that in essence
it is hypotonic. D10W is hypertonic.
A client has suffered an out-of-hospital cardiac arrest. The nurse prepares to institute therapeutic
hypothermia. What action by the nurse is inconsistent with this treatment modality?
Using two methods of temperature monitoring
Providing care with a ventilator bundle
Allowing shivering only during rewarming
Implementing pressure sore prevention methods - CORRECT ANSWER ✔✔ -Allowing
shivering only during rewarming-Shivering should not be allowed during therapeutic
hypothermia as is increases metabolic rate (and oxygen consumption) and causes coagulopathies.
Sedative are used to control shivering. The other actions are appropriate.
, A client is admitted with end-stage cancer and has several medications ordered for pain control,
including long-acting narcotics, non-narcotic pain medications, and medications for
breakthrough pain. The client complains loudly of pain of 2 on a 1-10 scale and is angry that the
pain cannot be controlled. Which intervention by the nurse is best?
Administer the medication for breakthrough pain.
Ask the client to explain more about the pain.
Inform the provider that the client needs more medication.
Teach the client how different pain medications work. - CORRECT ANSWER ✔✔ -Ask the
client to explain more about the pain.- The first step in the nursing process and the first step in
achieving pain control is assessment. There appears to be more occurring with this client that
simple pain control. In order to perform a holistic assessment, the nurse should listen
empathetically and have the client describe the current experience. After gathering date, the
nurse and client can work collaboratively to develop a pain management plan. The nurse realizes
that comfort is a holistic state under which pain management is achieved. The other options do
not include a holistic assessment but rather are reactive.
A client is given a new prescription for opioid pain medication to treat chronic pain and is also
given prescriptions for a stool softener and stimulant laxative. The client only wants to fill the
pain medication prescription. What response by the nurse is best?
"Well wait and see if you have constipation, then fill them if you do."
