1- A nurse is assessing a client who has a new diagnosis of colon cancer. Which of the
follow findings should the nurse report?
Answer: Hematochezia
2-
... [Show More] A nurse is assessing a client admitted with peripheral vascular disease. Which of the
following findings indicates a venous vascular disorder?
Answer: Edema of the ankle
3- A nurse is assessing a client who has pericarditis. In which of the following area of the
client’s chest should the nurse place the stethoscope to best hear a pericardial friction
rub?
Answer: D (on the picture)
4- A nurse is caring for a client who has a chest tube. The client asks why the fluid in the
water seal chamber rises and fails. Which of the following statements should the nurse
make?
Answer: You’re breathing pattern causes this
5- A community health nurse is reviewing home care instructions with an older adult
client who has a new diagnosis of heart failure. Which of the following is the priority
topic for the nurse to review with the client?
Answer: Changes weight
6- A nurse is planning care for syndrome of inappropriate antidiuretic hormone. Which of
the following interventions should the nurse include?
Answer: Check for increased urine specific gravity
7- A nurse is caring for a client who has a new onset of hyperglycemia hyperosmolar state
(HHS). Which of the following interventions by the nurse is the highest priority?
Answer: initiate IV fluid replacement
8- A nurse finds a client in bed, unresponsive and breathing. Which of the following
actions should the nurse take first?
Answer: Palpate for the client’s carotid pulse
9- A nurse is caring for a client who is experiencing a hypertensive crisis. Which of the
following actions should the nurse take?
apical Pulse
COMPLEX CMS EXAM - QUESTIONS AND ANSWERS GRADED A
Answer: Perform neurological assessment
10- A nurse is providing discharge teaching about blood glucose monitoring for a client
who has a new diagnosis of type 2 diabetes mellitus. The nurse should instruct the client
to obtain which of the following supplies?
Answer: Sterile lancets
11- A nurse is completing discharge teaching with a client who has a peripherally inserted
central catheter (PICC) line in the left arm. Which of the following instructions should
the nurse include in the teaching?
Answer: Use a 10ml syringe to flush the line
12- A nurse is preparing to administer naloxone 10mcg/kg via IV bolus to a client who
weights 220l. the amount available is 0.4 mg/mL. how many mL should the nurse
administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do
not use trailing zero)
Answer: 2.5
13- A nurse is caring for a client who has a sealed radiation implant. Which of the
following actions should the nurse take?
Answer: Limit family members visits to 30 minutes a day
14- A nurse is providing teaching to a client and his partner about performing peritoneal
dialysis at home. When discussing peritonitis, which of the following manifestations
should the nurse identify as the earliest indication of this complication?
Answer: cloudy effluent
15- A nurse is carring for a client who is receiving a blood transfusion. The nurse
observes that the client has bounding peripheral pulses, hypertension, and distended
jugular veins. The nurse should anticipate administering which of the following
prescribed medications?
Answer: Furosemide
16- A nurse is planning care for a client who has upper gastrointestinal bleeding due to a
peptic ulcer. Which of the following actions should the nurse plan to take?
Answer: Insert a large bore nasogastric tube
17- A nurse is caring for a client who has bladder cancer and a WBC count of 900/mm3.
Which of the following actions should the nurse take?
Answer: Instruct the client to avoid eating raw fruit
18- A nurse is caring for a client who has hypotension, cool and clammy skin,
tachycardia, and tachypnea in which of the following positions should the nurse place
the client
a) High fowlers
b) Reverse Trendelenburg
c) Side-lying
d) Feet elevated
19- A nurse is caring for a client who has sinus bradycardia and a heart rate of 42/min.
the client is receiving 0.9% sodium chloride IV at 75 mL an hour which of the following
actions should the nurse take first?
a) Check the client for hypotension
b) Administer supplemental oxygen
c) Prepare the client for transcutaneous pacing
d) Administer atropine 0.5 mg IV to the client – atropine slows everything down so
this can’t be it
20- A nurse is planning care for a client who has a central venous access device for
intermittent infusions. Which of the following actions should the nurse include in the
plan of care?
Answer: flush the catheter using a 10-mL syringe
21- A nurse is reviewing the medical record of a client who is to undergo open heart
surgery. Which of the following findings should the nurse report to the provider as a
contraindication to receiving heparin?
Answer: Thrombocytopenia
22- a nurse is caring for an older client who has dementia. Which of the following should
the nurse ask to assess the client’s abstract thinking?
Answer: What is meant by the saying “Don’t beat around the bush?”
23- a nurse is completing an assessment of an older adult client and notes reddened areas
over bony prominences, but the client’s skin is intact. Which of the following
interventions should the nurse include in the plan of care?
Answer: support bony prominences with pillows
24- a nurse is reviewing a cardiac rhythm strip of a client who has atrial flutter. Which of
the following findings should the nurse expect?
Answer: a saw-tooth pattern with atrial rate of 250/min to 400/min
25- a nurse is caring for a client who is scheduled for an abdominal paracentesis. The
nurse should plan which of the following actions?
Answer: ask the client to empty his bladder prior to the procedure
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26- a nurse is assessing a client following the insertion of a central venous catheter. Which
of the following findings indicates a pneumothorax?
Answer: Diminished breath sounds
27- A nurse is providing teaching to a client who is receiving opiods for pain
management. Which of the following information should the nurse include in the
teaching?
Answer: Monitor urinary output for retention
28- Missing
29- A nurse is providing preoperative teaching to a client who is having left-sided cardiac
catheterization. Which of the following information should the nurse include in the
teaching?
Answer: you should expect a warm sensation af [Show Less]