10/19/23,x1:27xPM FundamentalsxCMSxMidtermxTermsxinxthisxse
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FundamentalsxCMSxMidtermxTermsxinxthisxsetx(200)
Ax nursex isx assessingx thex heartx soundsx ofx ax clientx whox hasx developedx chestx painx thatx beco
mesxworsexwithxinspiration.
Thex nursex auscultatesxax high-xpitchedx scratchingxsoundx duringx bothx systolexandx diastolex withxthe
diaphragmxofxthexstethoscopexpositionedxatxthexlefxsternalxborder.xW
hichx ofx thex followingx heartx soundsx shouldx thex nursex document?
A. Audiblex Click
B. Murmur
C. Thirdx heartx sound
D. Pericardialx frictionx rub
Axnursexisxobtainingxthex bloodx pressurexinxaxclient'sxlowerxextremi
ty.xWhichxofxthexfollowingxactionxshouldxthexnursextake?
A. Auscultatexforxthexbloodxpresurexatx thexdorsalisxpedisxartery.
B. Measurex thex bloodx pressurex withx thex clientx sittingxonx thex sidex ofxthex bed.
C. Placexthexcufx 7.6cmx (3in)xabovexthex poplitealx artery.
D)x placex thex bladderx ofx thex cufx overx thex posteriorx aspectx ofx thex thigh
Axchargexnursexisxteachingxadultxcardiopulmonaryxresusciationx(CPR)xtoxaxgroupxofxnewl
yxlicensedxnurses.xWhichxofxthexfollowingxactionsxshouldxthexchargexnursexteachxasxthex
firstxresponsexinxCPR?
A. Callxforxassisstance
B. Beginx Chestx compressions
C. Confirmx unresponsiveness.
D. Givex rescuex breaths.
C) Confirmx unresponsiveness
Axnursexisxcaringxforxaxclientx whoxrequiresxaxchestxx-
ray.x Priorxtoxthexclientxbeingxtransportedxforxthexprocedure,xwhichxofxthexfollowingxactionsxsh
ouldxthexnursextakexfirst?
A. Explainxthexx-rayx procedurex toxthexclient.
B. Helpx thex clientx intoxax wheelchairx beforex thex transporterx arrives.
C. Askx ifx thex clientx hasx anyx questions.
D) Identifyx thex clientx usingx tox identifiers
Axnursexisxcaringxforxaxchildxwhoxisx postoperativexfollowingxax tonsillecto
my.xWhichxofxthexfollowingxactionsxshouldxthexnursextake?
A. Encouragex thex childx tox coughx frequentlyx tox clearx congestionx fromx anesthesia.
B. Placexaxheatingx padxatxthexchild'sxneckxforxcomfort.
C. Administerx analgesicsx tox thex childx onx ax routinex schedulex throughoutx thex dayx andx night.
D. Providexthexchildx withxicexcreamxwhenxoralxintakexisx initiated.
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Axnursex isxprovidingx teachingxtox axclientx whox hasx heartxfailurex aboutx howx toxreducexhisx d
ailyxintakexofxsodium.
Whichxofx thex followingxfactorsx isx thex mostx importantxinx determiningx thexclient'sx abilityx tox le
arnxnewxdietaryxhabits?
A. Thex involvementx ofx thex clientx inx planningx thex change.
B. Thex emphasisx thex providerx placesx onx thex dietaryx changes.
C. Thex learningx theoryx thex nursex usesx tox teachx thex dietaryx changes.
D. Thexextentxofx thexdietaryx changesx plannedx forxthex client.
Axchargex nursex isx observingxax newlyxlicensedx nursex performxtracheostomyxcarex forxaxclie
nt.xWhichxofxthexfollowingxactionsx byxthex newlyxlicensedxnursexrequiresxintervention?
A. Obtainingx hydrogenx peroxidexforx thextrachesotomyxcare.
B. Obtaingingxcottonx ballsx forxthex tracheostomyxcare.
C. Obtainingxsterilex glovesxforx thex tracheostomyx care.
D. Obtainingxaxsterilexbrushxforx thextracheostomyxcare.
Axnursexisx preparingx tox performx mouthxcarex forxanx unresponsivexclie
nt.xWhichxofxthexfollowingxactionsxshouldxthexnursexplanxtoxtake?
A. Placex thex clientx supine.
B. Keepx bothx sidex railsx up.
C. Raisexthex levelxofxthexbed.
D. Inspectx thex client'sx mouthx usingx ax fingerx sweep.
Axnursexisxwitnessingxaxclientxsignxanxinformedxconsentxformxforxsurgery.x
Whichx ofx thex followingx describesx whatx thex nursex isx affirmingx byx thisx actio
n?
A. Thex clientx fullyx understandsx thex provider'sx explannationx ofx thex procedure.
B. Thex clientx hasx beenx informedx aboutx thex risksx andxbenefitsx ofx thex procedure.
C. Thex nursex witnessedx thex provider'sxexplanantionxofx thexprocedu
re.xD.xThexsignaturexonxthex preoperativex consentxformx isxthexclient'
s.
Axnursexisx preparingx toxprovidex tracheostomyxcarexforxaxclient.x Whichxofx thexfollowingxacti
onsxshouldxthexnursextakexfirst?
A. Openx allx sterilex suppliesx andx solutions.
B. Stabilizex thex tracheostomyx tube.
C. Donxsterilex gloves
D. Performx handx hygiene
Axnursexisxcaringxforxanxolderxadultxclientxwhoxbecomesxagitatedxwhenxthexnursexrequestsxt
hatxthexclient'sxdenturesxbexremovedxpriorxtoxsurgery.xWhichxofxthexfollowingxresponsesxshoul
dxthexnursex.make?
A. It'sxforxyourxsafety. xDenturesxcanxslipxandxblockxyourxairwayxduringxsurgery.
B. Youxwouldn'txwantxyourxteethxtoxbexlostxorxbrokenxduringxsurgery,xwouldxyou?
C. Thexanesthesiologistxrequiresxeveryonextoxremovextheirxden
tures.xD.xWhatxworriesx youxaboutx beingx withoutxyourx teeth?
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Axnursexinx anxoncologyxclinicx isxassessingx axclientx whox isxundergoingxtreatmentx forx ovar
ianxcancer.xWhichxofxthexfollowingxstatementsxbyxthexclientxindicatesxshexisxexperiencingxps
ychologicalxdistress?
A. Myxparentsxarexretired,xandxtheyxhavexcomextoxhelpxoutxwithxourxchildren.
B. Ix amx goingx tox askx myx husbandx tox gox tox counselingx withx
me.xC.xIxkeepxhavingx nightmaresxaboutx myxupcomingxsurger
y.
D.xMyxgirlfriendsx boughtx mex ax nicex wig.
Axnursex onxax medical-
surgicalx unitx isxcaringx forxax client.xWhichx ofx thexfollowingx actionsxshouldxthexnursextakexfirstxw
henxusingxthexnursingxprocess?
A. Identifyx goalsxforxclientxcare.
B. Obtainx clientx information.
C. Documentx nursingx carex needs.
D. Evaluatexthexefectivenessxofxnursexcare.
Axnursexisxcaringxforxanxolderxadultxclientxwhoxisxviolentxandxattemptingxtoxdisconnectxherx
IVxlines.xThexproviderx prescribesxsofx wristxrestraints.xWhichx ofxthex followingx actionsxsho
uldxthexnursextakexwhilexthexclientxisxinxrestraints?
A. Tiexthexrestraintsx toxthexsidexrails.
B. Performx range-of-
motionxexercisesxtox thexwristsxeveryx 3xhrs.xC.xRemovexth
exrestraintsxonexatxaxtime.
D.xObtainxax PRNxprescriptionxforx thex restraints.
Axnursexisx planningxcarexforxaxclientx whox reportsx abdominalx pain.
Anxassessmentxbyx thexnursex revealsx thexclientx hasxaxtemperaturexofx3ffi.2x(102.6xF),x heartxrat
exofx105fimin,xaxsofxnontenderxabdomen,x andx mensesxoverduex byx2x days.xWhichxofxthexfollowi
ngxfindingsxshouldxbexthexnurse'sxpriority.
A. Heartx ratex 105fimin
B. sof,x nontenderx abdomen
C. temperature
D. overduex menses
Axnursexisx insertingxanxIVxcatheterxforx axclientx thatxresultsxinxax bloodxspillxonxherx glovedx h
and.xThexclientxhasxnoxdocumentedxbloodstreamxinfection.
Whichx ofx thex followingx actionsx shouldx thex nursex take?
A. Washxthexglovedxhandsxandx thenxthrowxthexglovesxaway.
B. Preparexanx incidentx reportx tox documentx thexevent.
C. Carefullyx removex thex glovesxandx followx withx handx hygiene.
D. Askxthex providerx toxorderxax bloodx culturextox determinex thexriskx ofx infection.
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Axnursex isxcaringxforxaxclientxwhox isxpostoperativexandxhasx paralyticxileus
.xWhichx ofx thex followingx abdominalx assessmentsx shouldx thex nursex expec
t?
A. Frequentx bowelx soundsx withx flatus.
B. Absentx bowelx soundsx withx distention
C. Hyperactivex bowelx soundsx withx diarrhea.
D. Normalx bowelx soundsx withx increasedx peristalsis.
Axnursex isxcaringxforxaxclientxwhoxhasx typex1xdiabetesx mellitusxandxisxresistantx toxlearningx
self-xinjectionxofxinsulin.xWhichxofxthexfollowingxstatementsxshouldxthexnursexmake?
A. "Tellxmex whatxIxcanx dox toxhelpx youxovercomexyourxfearxofxgivingx yourselfxinjections."
B. "Ixamxsurex yourxproviderxwillxnotx bex pleasedxthatxyouxrefusextox givex your
selfxinsulinxinjections."
C. "It'sxokay.xIxamxsurex yourxpartnerx willx bex ablex toxlearnx howxtox givex youx thexinsulinx injections."
D. "Youxwon'txbexablextoxgox
homexunlessxyouxlearnxtoxgiv
e
AxnursexisxrecievingxaxclientxfromxthexPACUxwhoxisxpostoperativexfollowingxabdominalxsurger
y.xWhichxofxthexfollowingxactionsxshouldxthexnursexmakextoxtransferxthexclientxfromxthexstre
tcherxtoxthexbed?
A. Lockxthex wheelsxonxthexbedxandxstretcher.
B. Instructx thexclientx toxraisexhisx armsxabovexhisx head.
C. Elevatex thexstretcherx2.5cmx (1in)xabovex thex heightx ofxthexbed.
D. Logxrollxthexclient.
Axnursexisxcaringxforxaxclientxwhoxisxinxthexterminalxstagexofxcancer.
Whichxofxthexfollowingxactionsxshouldxthexnursextakexwhenxshexobservesxthexclientxcrying?
A. Contactxthexfamilyxandxaskx themx toxstayx withxthexclient.
B. Oferxtoxcallxclient'sxminister.
C. Sitxandx holdx thex client'sx hand.
D. Leavexthexroomxandxallowx thexclientx toxcryxprivately.
Ax nursex inx anx emergencyx departmentx isx assessingx ax clientxwhox reportsx diarrheax a
ndxdecreasedxurinationxforx4xdays.
Whichxofxthex followingxactionsx shouldxthex nursex takex toxassessx thexclient'sx skinx turgor?
A. Pushxonx ax fingernailxbedx untilx itx blanches,xreleasex it,x andxobservex howx longx itxtakesx thex
skinxtoxbecomexpink.
B. Graspxax skinfoldx onx chestx underxclavicle,x release,x andx notex whetherx isxspringsx back.
C. Pressxthexskinxinxabovex thexanklex forx 5xseconds,x releasex it,xandxnotex thexdept
hxofxtheximpression.
D. Measurex thex skinxfoldx thicknessxatx thex upperx armx usingx axpairx ofxcalbratedx skinfoldxcalipers.
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FundamentalsxCMSxMidtermxTermsxinxthisxsetx(200)
Ax nursex isx assessingx thex heartx soundsx ofx ax clientx whox hasx developedx chestx painx thatx beco
mesxworsexwithxinspiration.
Thex nursex auscultatesxax high-xpitchedx scratchingxsoundx duringx bothx systolexandx diastolex withxthe
diaphragmxofxthexstethoscopexpositionedxatxthexlefxsternalxborder.xW
hichx ofx thex followingx heartx soundsx shouldx thex nursex document?
A. Audiblex Click
B. Murmur
C. Thirdx heartx sound
D. Pericardialx frictionx rub
Axnursexisxobtainingxthex bloodx pressurexinxaxclient'sxlowerxextremi
ty.xWhichxofxthexfollowingxactionxshouldxthexnursextake?
A. Auscultatexforxthexbloodxpresurexatx thexdorsalisxpedisxartery.
B. Measurex thex bloodx pressurex withx thex clientx sittingxonx thex sidex ofxthex bed.
C. Placexthexcufx 7.6cmx (3in)xabovexthex poplitealx artery.
D)x placex thex bladderx ofx thex cufx overx thex posteriorx aspectx ofx thex thigh
Axchargexnursexisxteachingxadultxcardiopulmonaryxresusciationx(CPR)xtoxaxgroupxofxnewl
yxlicensedxnurses.xWhichxofxthexfollowingxactionsxshouldxthexchargexnursexteachxasxthex
firstxresponsexinxCPR?
A. Callxforxassisstance
B. Beginx Chestx compressions
C. Confirmx unresponsiveness.
D. Givex rescuex breaths.
C) Confirmx unresponsiveness
Axnursexisxcaringxforxaxclientx whoxrequiresxaxchestxx-
ray.x Priorxtoxthexclientxbeingxtransportedxforxthexprocedure,xwhichxofxthexfollowingxactionsxsh
ouldxthexnursextakexfirst?
A. Explainxthexx-rayx procedurex toxthexclient.
B. Helpx thex clientx intoxax wheelchairx beforex thex transporterx arrives.
C. Askx ifx thex clientx hasx anyx questions.
D) Identifyx thex clientx usingx tox identifiers
Axnursexisxcaringxforxaxchildxwhoxisx postoperativexfollowingxax tonsillecto
my.xWhichxofxthexfollowingxactionsxshouldxthexnursextake?
A. Encouragex thex childx tox coughx frequentlyx tox clearx congestionx fromx anesthesia.
B. Placexaxheatingx padxatxthexchild'sxneckxforxcomfort.
C. Administerx analgesicsx tox thex childx onx ax routinex schedulex throughoutx thex dayx andx night.
D. Providexthexchildx withxicexcreamxwhenxoralxintakexisx initiated.
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t
Axnursex isxprovidingx teachingxtox axclientx whox hasx heartxfailurex aboutx howx toxreducexhisx d
ailyxintakexofxsodium.
Whichxofx thex followingxfactorsx isx thex mostx importantxinx determiningx thexclient'sx abilityx tox le
arnxnewxdietaryxhabits?
A. Thex involvementx ofx thex clientx inx planningx thex change.
B. Thex emphasisx thex providerx placesx onx thex dietaryx changes.
C. Thex learningx theoryx thex nursex usesx tox teachx thex dietaryx changes.
D. Thexextentxofx thexdietaryx changesx plannedx forxthex client.
Axchargex nursex isx observingxax newlyxlicensedx nursex performxtracheostomyxcarex forxaxclie
nt.xWhichxofxthexfollowingxactionsx byxthex newlyxlicensedxnursexrequiresxintervention?
A. Obtainingx hydrogenx peroxidexforx thextrachesotomyxcare.
B. Obtaingingxcottonx ballsx forxthex tracheostomyxcare.
C. Obtainingxsterilex glovesxforx thex tracheostomyx care.
D. Obtainingxaxsterilexbrushxforx thextracheostomyxcare.
Axnursexisx preparingx tox performx mouthxcarex forxanx unresponsivexclie
nt.xWhichxofxthexfollowingxactionsxshouldxthexnursexplanxtoxtake?
A. Placex thex clientx supine.
B. Keepx bothx sidex railsx up.
C. Raisexthex levelxofxthexbed.
D. Inspectx thex client'sx mouthx usingx ax fingerx sweep.
Axnursexisxwitnessingxaxclientxsignxanxinformedxconsentxformxforxsurgery.x
Whichx ofx thex followingx describesx whatx thex nursex isx affirmingx byx thisx actio
n?
A. Thex clientx fullyx understandsx thex provider'sx explannationx ofx thex procedure.
B. Thex clientx hasx beenx informedx aboutx thex risksx andxbenefitsx ofx thex procedure.
C. Thex nursex witnessedx thex provider'sxexplanantionxofx thexprocedu
re.xD.xThexsignaturexonxthex preoperativex consentxformx isxthexclient'
s.
Axnursexisx preparingx toxprovidex tracheostomyxcarexforxaxclient.x Whichxofx thexfollowingxacti
onsxshouldxthexnursextakexfirst?
A. Openx allx sterilex suppliesx andx solutions.
B. Stabilizex thex tracheostomyx tube.
C. Donxsterilex gloves
D. Performx handx hygiene
Axnursexisxcaringxforxanxolderxadultxclientxwhoxbecomesxagitatedxwhenxthexnursexrequestsxt
hatxthexclient'sxdenturesxbexremovedxpriorxtoxsurgery.xWhichxofxthexfollowingxresponsesxshoul
dxthexnursex.make?
A. It'sxforxyourxsafety. xDenturesxcanxslipxandxblockxyourxairwayxduringxsurgery.
B. Youxwouldn'txwantxyourxteethxtoxbexlostxorxbrokenxduringxsurgery,xwouldxyou?
C. Thexanesthesiologistxrequiresxeveryonextoxremovextheirxden
tures.xD.xWhatxworriesx youxaboutx beingx withoutxyourx teeth?
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Axnursexinx anxoncologyxclinicx isxassessingx axclientx whox isxundergoingxtreatmentx forx ovar
ianxcancer.xWhichxofxthexfollowingxstatementsxbyxthexclientxindicatesxshexisxexperiencingxps
ychologicalxdistress?
A. Myxparentsxarexretired,xandxtheyxhavexcomextoxhelpxoutxwithxourxchildren.
B. Ix amx goingx tox askx myx husbandx tox gox tox counselingx withx
me.xC.xIxkeepxhavingx nightmaresxaboutx myxupcomingxsurger
y.
D.xMyxgirlfriendsx boughtx mex ax nicex wig.
Axnursex onxax medical-
surgicalx unitx isxcaringx forxax client.xWhichx ofx thexfollowingx actionsxshouldxthexnursextakexfirstxw
henxusingxthexnursingxprocess?
A. Identifyx goalsxforxclientxcare.
B. Obtainx clientx information.
C. Documentx nursingx carex needs.
D. Evaluatexthexefectivenessxofxnursexcare.
Axnursexisxcaringxforxanxolderxadultxclientxwhoxisxviolentxandxattemptingxtoxdisconnectxherx
IVxlines.xThexproviderx prescribesxsofx wristxrestraints.xWhichx ofxthex followingx actionsxsho
uldxthexnursextakexwhilexthexclientxisxinxrestraints?
A. Tiexthexrestraintsx toxthexsidexrails.
B. Performx range-of-
motionxexercisesxtox thexwristsxeveryx 3xhrs.xC.xRemovexth
exrestraintsxonexatxaxtime.
D.xObtainxax PRNxprescriptionxforx thex restraints.
Axnursexisx planningxcarexforxaxclientx whox reportsx abdominalx pain.
Anxassessmentxbyx thexnursex revealsx thexclientx hasxaxtemperaturexofx3ffi.2x(102.6xF),x heartxrat
exofx105fimin,xaxsofxnontenderxabdomen,x andx mensesxoverduex byx2x days.xWhichxofxthexfollowi
ngxfindingsxshouldxbexthexnurse'sxpriority.
A. Heartx ratex 105fimin
B. sof,x nontenderx abdomen
C. temperature
D. overduex menses
Axnursexisx insertingxanxIVxcatheterxforx axclientx thatxresultsxinxax bloodxspillxonxherx glovedx h
and.xThexclientxhasxnoxdocumentedxbloodstreamxinfection.
Whichx ofx thex followingx actionsx shouldx thex nursex take?
A. Washxthexglovedxhandsxandx thenxthrowxthexglovesxaway.
B. Preparexanx incidentx reportx tox documentx thexevent.
C. Carefullyx removex thex glovesxandx followx withx handx hygiene.
D. Askxthex providerx toxorderxax bloodx culturextox determinex thexriskx ofx infection.
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Axnursex isxcaringxforxaxclientxwhox isxpostoperativexandxhasx paralyticxileus
.xWhichx ofx thex followingx abdominalx assessmentsx shouldx thex nursex expec
t?
A. Frequentx bowelx soundsx withx flatus.
B. Absentx bowelx soundsx withx distention
C. Hyperactivex bowelx soundsx withx diarrhea.
D. Normalx bowelx soundsx withx increasedx peristalsis.
Axnursex isxcaringxforxaxclientxwhoxhasx typex1xdiabetesx mellitusxandxisxresistantx toxlearningx
self-xinjectionxofxinsulin.xWhichxofxthexfollowingxstatementsxshouldxthexnursexmake?
A. "Tellxmex whatxIxcanx dox toxhelpx youxovercomexyourxfearxofxgivingx yourselfxinjections."
B. "Ixamxsurex yourxproviderxwillxnotx bex pleasedxthatxyouxrefusextox givex your
selfxinsulinxinjections."
C. "It'sxokay.xIxamxsurex yourxpartnerx willx bex ablex toxlearnx howxtox givex youx thexinsulinx injections."
D. "Youxwon'txbexablextoxgox
homexunlessxyouxlearnxtoxgiv
e
AxnursexisxrecievingxaxclientxfromxthexPACUxwhoxisxpostoperativexfollowingxabdominalxsurger
y.xWhichxofxthexfollowingxactionsxshouldxthexnursexmakextoxtransferxthexclientxfromxthexstre
tcherxtoxthexbed?
A. Lockxthex wheelsxonxthexbedxandxstretcher.
B. Instructx thexclientx toxraisexhisx armsxabovexhisx head.
C. Elevatex thexstretcherx2.5cmx (1in)xabovex thex heightx ofxthexbed.
D. Logxrollxthexclient.
Axnursexisxcaringxforxaxclientxwhoxisxinxthexterminalxstagexofxcancer.
Whichxofxthexfollowingxactionsxshouldxthexnursextakexwhenxshexobservesxthexclientxcrying?
A. Contactxthexfamilyxandxaskx themx toxstayx withxthexclient.
B. Oferxtoxcallxclient'sxminister.
C. Sitxandx holdx thex client'sx hand.
D. Leavexthexroomxandxallowx thexclientx toxcryxprivately.
Ax nursex inx anx emergencyx departmentx isx assessingx ax clientxwhox reportsx diarrheax a
ndxdecreasedxurinationxforx4xdays.
Whichxofxthex followingxactionsx shouldxthex nursex takex toxassessx thexclient'sx skinx turgor?
A. Pushxonx ax fingernailxbedx untilx itx blanches,xreleasex it,x andxobservex howx longx itxtakesx thex
skinxtoxbecomexpink.
B. Graspxax skinfoldx onx chestx underxclavicle,x release,x andx notex whetherx isxspringsx back.
C. Pressxthexskinxinxabovex thexanklex forx 5xseconds,x releasex it,xandxnotex thexdept
hxofxtheximpression.
D. Measurex thex skinxfoldx thicknessxatx thex upperx armx usingx axpairx ofxcalbratedx skinfoldxcalipers.
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