a nurse is caring for a client who had a total hip arthroplasty which of the following actions should the nurse take to prevent hip dislocation
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CMS NR341 QUESTIONS AND ANSWERS ALL CORRECT
A nurse is caring for a client who had a total hip arthroplasty. Which of the following actions should the
nurse take to prevent hip dislocation? Correct Answer: Place two bed pillows between the legs when in
bed.
A nurse is providing teaching to a client who has diabetes mellitus. Which of the following instructions
should the nurse provide to the client to help prevent the development of nephropathy? Correct
Answer: a. Controlling hypertension
A nurse in a long-term care facility is caring for a bedridden client. Which of the following findings
should alert the nurse to a potential complication of the client's immobility? Correct Answer: Confusion
A nurse is instructing a client who has a new diagnosis of type 1 diabetes mellitus about the sick-day
rules. Which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: "I will check my urine for ketones if my blood glucose is greater than 240 mg/dL."
1. A nurse is reviewing medications taken at home with a client who has angina. Which of the following
statements by the client indicates an understanding of the teaching?
I should withhold my metoprolol if my heart rate is above 100 bpm Correct Answer: I should lie down
before taking dose of isosorbide dinitrate
1. A nurse is teaching a client who has Graves' disease about recognizing the manifestation of thyroid
storm. Which of the following findings should the nurse include in the teaching? Correct Answer:
Increased temperature
1. A nurse is caring for a client who is receiving total parenteral nutrition through central line. The
current bag is nearly empty, and a new bag is unavailable from the pharmacy. Which of the following
actions should the nurse take? Correct Answer: Switch the infusion to a 10% dextrose solution.
A nurse is providing instructions about foot care for a client who has peripheral disease. The nurse
should identify that which of the following statements by the client indicates an understanding of the
teaching? Correct Answer: I rest in my recliner with my feet elevated for about an hour every afternoon
1. A nurse is providing discharge teaching to a client who has an ileostomy. Which of the following client
statements indicates an understanding of the teaching? Correct Answer: a. I will expect my stools to be
loose
11. A nurse is caring for a client who is receiving chemotherapy and requests information about
acupuncture to relieve some of the side effects. Which of the following findings should the nurse
identify as a contraindication to receiving this alternative therapy? Correct Answer: a. Lymphedema
1. A nurse is caring for a client who is 2 days postoperative following below the knee amputation and
asks about the purpose of maintaining an elastic bandage around the residual limb of the extremity.
Which of the following is an appropriate response by the nurse? Correct Answer: The elastic bandage
will prevent a postoperative wound infection
, 1. A nurse in the emergency department is caring for a client who is in hypovolemic shock. Which of the
following actions should the nurse take first? Correct Answer: Insert a large bore IV catheter
1. A nurse is providing discharge teaching to a client who has an impaired immune system due to
chemotherapy. Which of the following information should the nurse include in the teaching? Correct
Answer: Wash your perineal area two times each day with antimicrobial soap
A nurse is caring for a client who is receiving epidural analgesia. Which of the following findings is the
nurse's priority? Correct Answer: Hypotension
1. A nurse is reviewing the laboratory results of a client who has COPD and severe dyspnea. Which of the
following ABG values should the nurse expect? Correct Answer: PaCO2 48 mmHg
1. A nurse is planning care for a client following a cardiac catheterization. Which of the following actions
should the nurse take? Correct Answer: Maintain the client's affected extremity in extension
1. nurse is reviewing the medical record of a client who has nephrotic syndrome. Which of the following
findings should the nurse expect? Correct Answer: Proteinuria
1. A nurse is teaching a client about the use of an incentive spirometer. Which of the following
instructions should the nurse include in the teaching? Correct Answer: Hold breaths 3 to 5 seconds
before exhaling
1. A nurse is preparing a client who is to undergo a thoracentesis. The nurse should place the client in
which of the following positions? Correct Answer: Upright on the edge of the bed leaning over the
bedside table
1. A nurse is preparing to administer daily medications to a client who is undergoing a procedure at 1000
that requires IV contrast dye. Which of the following routine medications to give at 0800 should the
nurse withhold? Correct Answer: Metformin
1. A nurse is caring for a client who has contusion of the brainstem and reports thirst. The client's
urinary output was 4,000 mL over the past 24 hr. The nurse should anticipate a prescription for which of
the following IV medications? Correct Answer: Desmopressin
1. A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral
resection of the prostate. The client reports spasms and the nurse observes decreased urinary output.
Which of the following actions should the nurse take? Correct Answer: Flush the catheter manually with
0.9% sodium chloride
Patient with lumbar puncture order, what position should nurse have him in Correct Answer: laying in
bed in cannonball position (diagram 4)
1. A nurse is assessing a client who has an arteriovenous (AV) fistula in the left forearm. Which of the
following findings should the nurse identify as an indication of a complication at the vascular access site?
Correct Answer: Absence of bruit
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