NR 329 Fundamentals CMS Midterm Terms in this set (200)Q & A Latest updated 2022
A nurse is assessing the heart sounds of a client who has developed
... [Show More] chest pain that becomes worse with inspiration.
The nurse auscultates a high- pitched scratching sound during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border.
Which of the following heart sounds should the nurse document?
A. Audible Click
B. Murmur
C. Third heart sound
D. Pericardial friction rub
A nurse is obtaining the blood pressure in a client's lower extremity.
Which of the following action should the nurse take?
A. Auscultate for the blood presure at the dorsalis pedis artery.
B. Measure the blood pressure with the client sitting on the side of the bed.
C. Place the cuff 7.6cm (3in) above the popliteal artery.
D) place the bladder of the cuff over the posterior aspect of the thigh
A charge nurse is teaching adult cardiopulmonary resusciation (CPR) to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR?
A. Call for assisstance
B. Begin Chest compressions
C. Confirm unresponsiveness.
D. Give rescue breaths.
C) Confirm unresponsiveness
A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported for the procedure, which of the following actions should the nurse take first?
A. Explain the x-ray procedure to the client.
B. Help the client into a wheelchair before the transporter arrives.
C. Ask if the client has any questions. D) Identify the client using to identifiers
A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take?
A. Encourage the child to cough frequently to clear congestion from anesthesia.
B. Place a heating pad at the child's neck for comfort.
C. Administer analgesics to the child on a routine schedule throughout the day and night.
D. Provide the child with ice cream when oral intake is initiated.
A nurse is providing teaching to a client who has heart failure about how to reduce his daily intake of sodium.
Which of the following factors is the most important in determining the client's ability to learn new dietary habits?
A. The involvement of the client in planning the change.
B. The emphasis the provider places on the dietary changes.
C. The learning theory the nurse uses to teach the dietary changes.
D. The extent of the dietary changes planned for the client.
A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention?
A. Obtaining hydrogen peroxide for the trachesotomy care. B. Obtainging cotton balls for the tracheostomy care.
C. Obtaining sterile gloves for the tracheostomy care.
D. Obtaining a sterile brush for the tracheostomy care.
A nurse is preparing to perform mouth care for an unresponsive client.
Which of the following actions should the nurse plan to take?
A. Place the client supine.
B. Keep both side rails up. C. Raise the level of the bed.
D. Inspect the client's mouth using a finger sweep.
A nurse is witnessing a client sign an informed consent form for surgery. Which of the following describes what the nurse is affirming by this action?
A. The client fully understands the provider's explannation of the procedure.
B. The client has been informed about the risks and benefits of the procedure.
C. The nurse witnessed the provider's explanantion of the procedure. D. The signature on the preoperative consent form is the client's.
A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first?
A. Open all sterile supplies and solutions.
B. Stabilize the tracheostomy tube.
C. Don sterile gloves
D. Perform hand hygiene
A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client's dentures be removed prior to surgery. Which of the following responses should the nurse .make?
A. It's for your safety. Dentures can slip and block your airway during surgery.
B. You wouldn't want your teeth to be lost or broken during surgery, would you?
C. The anesthesiologist requires everyone to remove their dentures. D. What worries you about being without your teeth?
A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress?
A. My parents are retired, and they have come to help out with our children.
B. I am going to ask my husband to go to counseling with me. C. I keep having nightmares about my upcoming surgery.
D. My girlfriends bought me a nice wig.
A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse take first when using the nursing process?
A. Identify goals for client care. B. Obtain client information.
C. Document nursing care needs.
D. Evaluate the effectiveness of nurse care.
A nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints?
A. Tie the restraints to the side rails.
B. Perform range-of-motion exercises to the wrists every 3 hrs. C. Remove the restraints one at a time.
D. Obtain a PRN prescription for the restraints.
A nurse is planning care for a client who reports abdominal pain.
An assessment by the nurse reveals the client has a temperature of 39.2 (102.6 F), heart rate of 105/min, a soft nontender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse's priority.
A. Heart rate 105/min
B. soft, nontender abdomen C. temperature
D. overdue menses
A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection.
Which of the following actions should the nurse take?
A. Wash the gloved hands and then throw the gloves away.
B. Prepare an incident report to document the event.
C. Carefully remove the gloves and follow with hand hygiene.
D. Ask the provider to order a blood culture to determine the risk of infection.
A nurse is caring for a client who is postoperative and has paralytic ileus. Which of the following abdominal assessments should the nurse expect?
A. Frequent bowel sounds with flatus. B. Absent bowel sounds with distention
C. Hyperactive bowel sounds with diarrhea.
D. Normal bowel sounds with increased peristalsis.
A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning self- injection of insulin. Which of the following statements should the nurse make?
A. "Tell me what I can do to help you overcome your fear of giving yourself injections."
B. "I am sure your provider will not be pleased that you refuse to give yourself insulin injections."
C. "It's okay. I am sure your partner will be able to learn how to give you the insulin injections."
D. "You won't be able to go home unless you learn to give
A nurse is recieving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse make to transfer the client from the stretcher to the bed?
A. Lock the wheels on the bed and stretcher.
B. Instruct the client to raise his arms above his head.
C. Elevate the stretcher 2.5cm (1in) above the height of the bed.
D. Log roll the client.
A nurse is caring for a client who is in the terminal stage of cancer.
Which of the following actions should the nurse take when she observes the client crying?
A. Contact the family and ask them to stay with the client.
B. Offer to call client's minister. C. Sit and hold the client's hand.
D. Leave the room and allow the client to cry privately.
A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days.
Which of the following actions should the nurse take to assess the client's skin turgor?
A. Push on a fingernail bed until it blanches, release it, and observe how long it takes the skin to become pink.
B. Grasp a skinfold on chest under clavicle, release, and note whether is springs back.
C. Press the skin in above the ankle for 5 seconds, release it, and note the depth of the impression.
D. Measure the skin fold thickness at the upper arm using a pair of calbrated skinfold calipers.
A nurse is caring for a client who has terminal illness.
The client asks several questions about the nurse's religion beliefs related to death and dying. Which of the following actions should the nurse take?
A. Change the topic because the client is trying to divert attention from the illness to the nurse. B. Encourage the client to express his thoughts about death and dying.
C. Tell the client that religious beliefs are a personal matter.
D. Offer to contact the client's minister or the facility's chaplain.
A nurse is caring for a client who is unstable and has vital signs measured every 15 min by an electronic blood pressure machine.
The nurse notices the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take?
A. Turn on the machine every 15 min to measure the client's blood pressure.
B. Record only blood pressure readings needed for the 15-min intervals.
C. Obtain manural and automatic readings and compare them/.
D. Disconnect the machine, and measure the blood pressure manually every 15 min.
A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to wheelchair.
Which of the following techniques should the nurse use?
A. Stand toward the client's stronger side.
B. Instruct the client to lean backward from the hips. C. Place the wheelchair at a 45degree angle to the bed.
D. Assume a narrow stance with feet 15 cm (6in) apart.
Place in order: Inspection, Auscultation, Palpation, Percussion
Inspection Palpation Percussion Auscultation
A nurse is preparing a client who is scheduled for a hysterectomy for transport to the operating room, when the client states she no longer wants to have the surgery. Which of the following actions should the nurse take?
A. Tell the client it is too late for her to change her mind because the surgery is already scheduled.
B. Telephone the operating room and cancel the surgery. C. Inform the client's family about the situation.
D. Notify the provider about the client's decision.
A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand- washing technique?
A. The nurse washes each part of her hands with 5 strokes.
B. The nurse washes from the elbows down to the hands.
C. the nurse washes with her hands held higher then her elbows.
D. The nurse uses minimal friction when washing her hands.
A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month that might require a blood transfusion.
The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following statements should the nurse make to the client?
A. "Ask your provider to prescribe epoetin before the surgery."
B. "You should ask your provider about taking iron supplements prior to the surgery."
C. Request a family member to donate blood for you." D. "Donate autologous blood before the surgery.
A nurse is teaching an assistive personnel (AP) about proper hand hygiene.
Which of the following statements by the AP indicates an understanding of the teaching?
A. "There are times I should use soap and water rather than an alcohol-based hand rub to clean my hands."
B. "I will use cold water when I wash my hands to protect my skin from becoming too dry." C. "I will apply friction for at least 10 seconds while washing my hands."
D. "After washing my hands I will dry them from the elbows down."
A nurse is measuring vital signs for a client and notices an irregularity in the pulse.
Which of the following actions should the nurse take?
A. Measure the pulse using a Doppler ultrasound stethoscope.
B. Check the client's pedal pulses.
C. Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart.
D. Take the pulse at each peripheral site and count the rate for 30 seconds.
A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular size cuff for a client who is obese. Which of the following explanations should the nurse give the AP?
A. "The reading will be inaudible if the cuff is too small for the client."
B. "The width of the cuff bladder should be 75% of the circumference of the client's arm."
C. As long as the cuff will circle the arm the reading will be accurate.
D. "Using a cuff that is too small will result in an inaccurately high reading."
A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who will have emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client?
A. The client asks the nurse to repeat the instructions before attempting the exercise. B. The client reports severe pain.
C. The client asks the nurse how often deep breathing should be done after surgery. D. The client tells the nurse that this exercise will probably be painful after surgery.
A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching.
A. "Drink a min. of 1,000 mL of fluid daily."
B. "Increase your intake of refined-fiber foods" C. "Sit on the toilet 30 min after eating a meal.
D. "Take a laxative every day to maintain regularity."
A nurse is planning to obtain the vital signs of a 2 year old child who is experiencing diarrhea and who might have a right ear infection.
Which of the following routes should the nurse use to obtain the temperature?
A. Rectal
B. Tympanic
C. Oral
D. Temporal
D) Temporal
A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a secondary prevention.
A. Holding a community clinic to adminster influenza immunizations.
B. Screening groups of older adults in nursing care facilites for early influenza manifestations.
C. Educating parents of young children about dangers of influenza.
D. Finding rehabilitation programs for older adults who have complications from influenza.
Which of the following actions should the nurse take first? A. Evaluate pedal pulses.
B. Obtain a medical history.
C. Measure vital signs.
D. Assess for leg pain.
A nurse on a medical-surgical unit is admitting a client.
Which of the following information should the nurse document in the client's record first? A. Assessment
B. Plan of care
C. Nursing interventions performed.
D. Evaulation of progress.
A nurse is teaching a group of older adults about expected changes of aging.
Which of the following statements by a group member indicates that the teaching has been effective?
A. "I should expect my heart rate to take longer to return to normal after exercise as I get older."
B. "Urinary incontinence is something I will have to live with as I grow older."
C. "I can expect to have less ear wax as I get older."
D. "My stomach will empty more quickly after meals as I grow older."
A nurse is planning weight loss strategies for a group of clients who are obese.
Which of the following actions by the nurse will improve the client's commitment to a long- term goal of weight loss?
A. Attempt to increase the client's self motivation
B. Keep detailed records of each client's progress.
C. Test client learning after each teaching session.
D. Avoid discussing areas that might cause client anxiety.
A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethescope to auscultate the aortic valve?
A. Fifth intercostal space just medical to the midclavicular line
B. Second intercostal space to the left of the sternum
C. Fifth intercostal space to the left of the sternum
D. Second intercostal space to the right of the sternum.
A nurse is discussing A restorative Health care with a B newly licensed nurse. Which of D the following examples should
the nurse include in the teaching? (Select all that apply).
A. Home health care
B. Rehabilitation facilities
C. Diagnostic centers
D. Skilled nursing facilities
E. Oncology centers
A nurse is explaining the B various types of health care E coverage clients might have to a group of nursing students.
Which of the following healthcare financing mechanisms are federally funded? (Select all that apply).
A. Preferred provider organization (PPO)
B. Medicare
C. Long term care insurance
D. Exclusive provider organization (EPO)
E. Medicaid
A nurse manager is developing A strategies to care for the increasing number of clients
who have obesity. Which of the
following actions should the nurse include as a primary healthcare strategy?
A. Collaborating with providers to perform obesity screenings during routine office visits
B. Ensuring the availability of specialized beds in rehabilitation centers for clients who have obesity
C. Providing specialized intraoperative training regarding surgical treatments for obesity
D. Educating acute care nurses on post operative complications related to obesity Fundamentals CMS Midterm
A nurse is discussing the B purpose of regulatory
agencies during a staffmeeting. Which of the following tasks should the nurse identify as a responsibility of state licensing boards?
A. Monitoring evidence-based practice for clients who have a specific diagnosis
B. Ensuring that healthcare providers comply with regulations
C. Setting quality standards for accreditation of healthcare facilities
D. Determining if medications are safe for administration to clients Fundamentals CMS Midterm
A nurse is explaining the A various levels of healthcare B services to a group of newly C licensed nurses. Which of the
following examples of care or care settings should the nurse classify as tertiary? (Select all that apply)
A. Intensive care unit
B. Oncology treatment center C. Burn center
D. Cardiac rehabilitation
E. Home healthcare Fundamentals CMS Midterm
A nurse is caring for a group of A clients on a medical surgical B unit. For which of the following D client care needs should the
nurse initiate a referral for a social worker? (Select all that apply)
A. A client who has terminal cancer requests hospice care in her home
B. A client asks about community resources available for older adults
C. A client states that she wants her child baptized before surgery
D. A client requests an electric wheelchair for use after discharge
E. A client states that he does not understand how to use a nebulizer Fundamentals CMS Midterm
A goal for a client who has D difficulty with self-feeding due to rheumatoid arthritis is to use
adaptive devices. The nurse
caring for the client should initiate a referral to which of the following members of the interprofessional care team?
A. Social worker
B. Certified nursing assistant C. Registered dietitian
D. Occupational therapist
A client who is postoperative A following knee arthroplasty is C concerned about the adverse D effects of the medication he is
receiving for pain management. Which of the following members of the interprofessional care team can assist the client in understanding the medications affects? (Select all that apply)
A. Provider
B. Certified nursing assistant C. Pharmacist
D. Registered nurse
E. Respiratory therapist Fundamentals CMS Midterm
A client who has had a CVA D (cerebrovascular accident) has persistent problems with
dysphasia. The nurse caring for
the client should initiate a referral with which of the following members of the interprofessional team?
A. Social worker
B. Certified nursing assistant C. Occupational therapist D. Speech-language pathologist A nurse is equating a group of A newly licensed nurses with the B roles of the various
members C of the healthcare team they will E encounter on a medical
surgical unit. When she gives examples of the types of tasks CNAs may perform which of the following client activities should she include? (Select all that apply)
A. Bathing
B. Ambulating
C. Toileting
D. Determining pain level E. Measuring vital signs Fundamentals CMS Midterm
A nurse is caring for a client B who decides not to have surgery despite significant
blockages in his coronary
arteries. The nurse understands that this clients choice is an example of which of the following ethical principles?
A. Fidelity
B. Autonomy
C. Justice
D. Nonmaleficence
A nurse offers pain medication D to a client who is postoperative prior to ambulation. The nurse understands that this aspect of
care delivery is an example of which of the following ethical principles?
A. Fidelity
B. Autonomy C. Justice
D. Beneficence
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A nurse is instructing a group C of nursing students about the responsibilities organ donation and procurement involve.
When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the nurse should understand that this aspect of care delivery is an example of which of the following ethical principles?
A. Fidelity
B. Autonomy
C. Justice
D. Nonmaleficence
A nurse questions a medication D prescription as too extreme in light of the clients advanced
age and unstable status. The
nurse understands that this action is an example of which of the following ethical principles?
A. Fidelity
B. Autonomy
C. Justice
D. Nonmaleficence Fundamentals CMS Midterm
A nurse is instructing a group C of nursing students about how to know and what to expect
when ethical dilemmas arise.
Which of the following situations should the students identify as an ethical dilemma?
A. A nurse on a medical surgical unit demonstrate signs of chemical impairment.
B. A nurse overhears another nurse telling an older adult client that if he doesn't stay in bed, she will have to apply restraints.
C. A family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill
D. A client who is terminally ill hesitates to name her spouse on her durable power of attorney form.
Fundamentals CMS Midterm
A nurse observes an AP A reprimanding a client for not using the urinal properly. The
AP tells him she will put a
diaper on him if he does not use the urinal more carefully next time. Which of the following torts is the AP committing?
A. Assault
B. Battery
C. False imprisonment D. Invasion of privacy
A nurse is caring for a B competent adult client who tells the nurse that he's thinking
about leaving the hospital
against medical advice. The nurse believes that this is not in the clients best interest, so she prepares to administer a PRN sedative medication the client has not requested along with his usual medication. Which of the following types of tort is the nurse about to commit?
A. Assault
B. False imprisonment
C. Negligence
D. Breach of confidentiality Fundamentals CMS Midterm
A nurse in a surgeon's office is C providing preoperative teaching for a client who is
scheduled for surgery the
following week. The client tells the nurse that he will prepare his advance directives before he goes to the hospital. Which of the following statements made by the client should indicate to the nurse an understanding of advance directives?
A. I'd rather have my brother make decisions for me, but I know it has to be my wife.
B. I know they won't go ahead with the surgery unless I prepare these forms.
C. I plan to write that I don't want them to keep me on a breathing machine.
D. I will get my regular doctor to approve my plan before I hand it in at the hospital. Fundamentals CMS Midterm
A nurse is caring for a client A who is about to undergo an B elective surgical procedure.
The nurse should take which of
the following actions regarding informed consent? (Select all that apply)
A. Make sure the surgeon obtained the clients consent B. Witness the client signature on the consent form
C. Explain the risks and benefits of the procedure
D. Describe the consequences of choosing not to have the surgery
E. Tell the client about alternatives to having the surgery Fundamentals CMS Midterm
A nurse has noticed several C occasions in the past week on another nurse on the unit seem
drowsy and unable to focus on
the issue at hand. Today, she found the nurses sleep in a chair in the break room when she was not on a break. Which of the following actions should the nurse take?
A. Alert the ANA
B. Fill out an incident report C. Report the observations to the nurse manager on the unit D. Leave the nurse alone to sleep
A nurse is preparing C information for a change of shift report; which of the
following information should the nurse include in the report?
A. Input and output for the shift B. Blood pressure from the previous day
C. Bone scan scheduled for today
D. Medication routine from the medication administration record Fundamentals CMS Midterm
A nurse is discussing the HIPAA B Privacy rule with nurses during C new employee orientation. D Which of the following E information should the nurse
include? (Select all that apply)
A. A single electronic records password is provided for nurses on the same unit
B. Family members should provide a code prior to receiving client health information
C. Communication of client information can occur at the nurses station.
D. A client can request a copy of her medical record
E. A nurse my photo copy a clients medical record for transferred to another facility Fundamentals CMS Midterm
A nurse is reviewing B documentation with a group of C newly licensed nurses. Which of the following legal
guidelines should be followed when documenting in a clients record? (Select all that apply)
A. Cover errors with correction fluid and write in the correct information
B. Put the date and time on all entries
C. Document objective data leaving out opinions
D. Use as many abbreviations as possible
E. Wait until the end of the shift to document
A nurse is discussing A occurrences that require B completion of an incident D report with a newly licensed
nurse. Which of the following should the nurse include in the teaching? (Select all that apply)
A. Medication error
B. Needle sticks
C. Conflict with provider and nursing staff
D. Omission of prescription
E. Missed specimen collection of a prescribe laboratory test Fundamentals CMS Midterm
A nurse is receiving a providers A prescription by telephone for B morphine for a client who is C reporting moderate to severe
pain. Which of the following nursing actions are appropriate? (Select all that apply)
A. Repeat the details of the prescription back to the provider
B. Have another nurse listen to the telephone prescription
C. Obtain providers signature on the prescription within 24 hours
D. Decline the verbal prescription because it is not an emergency situation
E. Tell the charge nurse that the provider has prescribed morphine by telephone. Fundamentals CMS Midterm
A nurse on a medical surgical C unit has received change of shift report and will care for
four clients. Which of the
following clients needs should the nurse assigned to an AP?
A. Updating the plan of care for a client who is post operative
B. Reinforcing teaching with a client who is learning to walk using a quad
C. Reapplying a condom catheter for a client who has urinary incontinence
D. Applying a sterile dressing to a pressure ulcer
A nurse manager of a medical B surgical unit is assigning care responsibilities for the oncoming shift. A client is
awaiting transfer back to the unit from the PACU following thoracic surgery. To which of the following staff members should the nurse assigned the client?
A. Charge nurse
B. RN
C. Practical nurse (PN)
D. Assistive personnel (AP) Fundamentals CMS Midterm
A nurse is delegating the B ambulation of a client who had C knee arthroplasty five days ago D to an AP. Which of the
following information should the nurse share with the AP? (Select all that apply)
A. The roommate ambulates independently
B. The client ambulates with his slippers on over his antiembolic stockings.
C. The client uses a front- wheeled walker when ambulating
D. The client had pain medication 30 minutes ago
E. The client is allergic to codeine
F. The client 850% of his breakfast this morning Fundamentals CMS Midterm
An RN is making assignments D for a PN at the beginning of the shift which of the following
assignments should the PN question?
A. Assisting a client who is 24 hour post operative to use an incentive spirometer
B. Collecting a clean catch urine specimen from a client who has a wound infection
C. Providing nasopharyngeal suctioning for a client who has pneumonia
D. Teaching a client who has asthma to use a metered dose inhaler
A nurse is preparing an in- B service program about C delegation. Which of the E following elements should she
identify when presenting the five rights of delegation? (Select all that apply)
A. Right client
B. Right supervision and evaluation
C. Right direction and communication
D. Right time
E. Right circumstances Fundamentals CMS Midterm
By the second postoperative A day a client has not achieved satisfactory pain relief. Based
on this evaluation, which of the
following actions should the nurse take, according to the nursing process?
A. Reassess the client to determine the reasons for an adequate pain relief
B. Wait to see whether the pain lessons during the next 24 hours
C. Change the plan of care to provide different pain relief interventions
D. Teach the client about the plan of care for managing his pain. Fundamentals CMS Midterm
A newly licensed nurse is A reporting to the charge nurse about the care she gave to a
client.
She states, "the client said his leg pain was back, so I checked his medical record, and he last received his pain medication six hours ago. The prescription reads every four hours PRN for pain, so I decided he needs it. I asked the unit nurse to observe me preparing and administering it. I checked with the client 40 minutes later, and he said his pain is going away." The charge nurse should inform the newly licensed nurse that she left out which of the following steps of the nursing process?
Fundamentals CMS Midterm
A charge nurse is reviewing the A steps of the nursing process D with a group of nurses.
Which E of the following data should
the charge nurse identify as objective data? (Select all that apply)
A. Respiratory rate is 22/min with even, unlabored respirations.
B. The clients partner states, "he said he hurts after walking about 10 minutes."
C. Pain rating is three on a scale of 0 to 10
D. Skin is pink, warm, and dry E. The AP reports the client walked with a limp Fundamentals CMS Midterm
A charge nurse is talking with a C newly licensed nurse and is D reviewing nursing interventions E that do not require a providers prescription. Which of the
following interventions should the charge nurse include? (Select all that apply)
A. Writing a prescription for morphine sulfate as needed for pain
B. Inserting a nasogastric (NG tube) to relieve gastric distention
C. Showing a client how to use progressive muscle relaxation D. Performing a daily bath after the evening meal
E. Re-positioning a client every two hours to reduce pressure ulcer risk.
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