Series (CMS) Exams STUDY GUIDE ACTUAL EXAM
A nurse is collecting data from a client who has acute cholecystitis.
Which of the following manifestations should the nurse expect? -
CORRECT ANSWER Pain radiating to the right shoulder.
A nurse is reinforcing teaching with a client who has a prescription for
clopidogrel following a thrombotic stroke. Which of the following
information should the nurse include in the teaching? - CORRECT
ANSWER "The medication prevents clot formation."
A nurse is contributing to the plan of care for a client who is in
skeletal traction. Which of the following interventions should the nurse
include? - CORRECT ANSWER Keep the client's body centered in the
bed.
A nurse is contributing to the plan of care for a client who has
dysphagia following a stroke. Which of the following actions should
the nurse include in the plan of care to prevent aspiration? - CORRECT
ANSWER Keep the client upright for 30 min after a meal.
A nurse is reinforcing postoperative teaching with a client who is
scheduled for cataract surgery on his right eye. Which of the following
instructions should the nurse include? - CORRECT ANSWER "Wear a
protective eye shield while sleeping."
A nurse is collecting data from a client who was admitted with a
Glasgow coma scale (GCS) of 3. Which of the following findings should
the nurse expect? - CORRECT ANSWER Nonresponsive to commands.
A nurse is caring for a client who has type 1 diabetes mellitus and has
undergone a below-the-knee amputation. Which of the following is the
highest priority finding? - CORRECT ANSWER Skin flap of the residual
limb is cool to the touch.
,A nurse is reinforcing teaching about the prevention of sexually
transmitted infections (STIs) which a client who is sexually active.
Which of the following information should the nurse include in the
teaching? - CORRECT ANSWER Inserting a polyurethane female
condom is effective for prevention of STIs.
A nurse is administering a tap water enema to a client who has
constipation. The client reports abdominal cramping during
installation of the enema. Which of the following actions should the
nurse take? - CORRECT ANSWER Slow the rate of fluid flow.
A nurse is reinforcing teaching about mammograms which an adult
client who is postmenopausal. Which of the following statements
indicates to the nurse that the client understands the teaching? -
CORRECT ANSWER "I should have a mammogram every 1 to 2
years."
A nurse is collecting data from a client and osculates intermittent
high-pitched sounds during inspiration over the lower base of the
lungs. The nurse should identify this finding as which of the following
lung sounds? - CORRECT ANSWER Fine crackles
A nurse is assisting with the care of four clients. Which of the
following clients is the priority for the nurse to see? - CORRECT
ANSWER A client who has chest tubes and an oxygen saturation of
90%
A nurse is preparing to perform a closed irrigation of an indwelling
urinary catheter for a client who had abdominal surgery. Which of the
following actions should the nurse plan to take? - CORRECT ANSWER
Stop the irrigation if resistance is felt during fluid instillation.
A nurse is reviewing the medical record of a client who has systemic
lupus erythematous (SLE). Which of the following findings should the
nurse expect? - CORRECT ANSWER Joint pain
A nurse is preparing to transfer a client from a bed to a chair following
a total knee arthroplasty. The client has a prescription for partial
,weight bearing. Which of the following actions should the nurse take? -
CORRECT ANSWER Position feet apart before pivoting the client.
A nurse is reviewing principles of body mechanics which a client
following a lumbar laminectomy. Which of the following statements by
the client indicates an understanding of the teaching? - CORRECT
ANSWER "I will flex at the knees and use my leg muscles to lift an
object off the floor."
A nurse is caring for a client who is preoperative and does not speak
the same language as the nurse. Which of the following actions should
the nurse take? - CORRECT ANSWER Incorporate the use of pictures
as a communication tool.
A nurse is reinforcing teaching with a client who is scheduled for an
electroencephalogram (EEG). Which of the following information
should the nurse include in the teaching? - CORRECT ANSWER
"Shampoo your hair the night before the procedure."
A nurse is caring for a client who has a new diagnosis of moderate
Alzheimer's disease. Which of the following provider prescriptions
should the nurse expect? - CORRECT ANSWER Donepezil 5mg PO
daily
A nurse is collecting data from a client who has left homonymous
hemianopsia following a stroke. Which of the following client findings
indicates effective management of homonymous hemianopsia? -
CORRECT ANSWER Eats items from both sides of the lunch tray.
A nurse is reinforcing teaching bout preventing UTIs with a female
client. Which of the following statements by the client indicates an
understanding of the information? - CORRECT ANSWER "I will
increase my intake of water."
A nurse is reinforcing teaching with a client about advance directives.
The nurse should identify that which of the following client responses
indicates an understanding of the teaching? - CORRECT ANSWER "If
, I have advance directives with a do-not-resusciate order, I can change
it later."
A nurse is reinforcing discharge teaching with a client who has a new
cast. The client is prescribed hydrocodone for the pain. The nurse
should instruct the client to report immediately which of the following
findings to the provider? - CORRECT ANSWER Swelling of the
affected extremity.
A nurse is caring for a client who is experiencing difficulty using
utensils to eat following a stroke. Which of the following referrals
should the nurse recommend? - CORRECT ANSWER Occupational
therapist
A nurse is reinforcing teaching with a client who is experiencing
neutropenia as a result of chemotherapy. Which of the following
information should the nurse include? - CORRECT ANSWER Bathe
with antimicrobial soap daily.
Take temperature daily.
Avoid gardening.
A nurse is collecting data from a client who has diabetes myelitis and
a blood because level of 61 mg/dL. Which of the findings should the
nurse expect? - CORRECT ANSWER Difficulty concentrating.
The nurse is reinforcing teaching with a client who has a history of
calcium oxalate kidney stones. Which of the following statements by
the client indicates an understanding of the instructions? - CORRECT
ANSWER "I'll be sure to eliminate peanuts from my diet."
A nurse is caring for a client who is receiving bolus enteral feedings
and is prescribed digoxin and furosemide. Which of the following
actions should the nurse take? - CORRECT ANSWER Flush the tube
with water before and after each medication.