Exam (elaborations)
ATI CMS FUNDAMENTALS – QUESTIONS AND ANSWERS
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ATI CMS FUNDAMENTALS – QUESTIONS AND ANSWERS
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ATI CMS FUNDAMENTALS – QUESTIONS AND ANSWERSA 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 the client's minister
C. Sit and hold the client's hand
D. Leave the room and allow the client to cry privately Correct Ans - C. Sit
and hold the client's hand
A nurse is caring for a client who requires wrist restraints. Which of the following actions should the nurse take?
A. Tie a secure knot with the restraint straps
B. Attach the restraints' straps to the bed's side rails
C. Make sure 3 fingers fit beneath the restraints
D. Remove the restraints at least every 2 hrs Correct Ans - D. Remove the
restraints at least every 2 hrs
After collecting data on a client's radial pulses, the nurse documents "radial pulses 4+ bilaterally." This finding indicates which of the following pulse qualities?
A. Bounding
B. Full
C. Variable
D. Weak Correct Ans - A. Bounding
A nurse is reinforcing teaching with a client regarding protein intake. Which of the following foods should the nurse include as an example of an incomplete protein?
A. Eggs
B. Soybeans
C. Lentils
D. Yogurt Correct Ans - C. Lentils
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 clients' commitment to a long-term goal of weight loss?
A. Attempting to increase the clients' self-motivation
B. Keeping detailed records of each client's progress
C. Testing client learning after each teaching session
D. Avoiding discussing topics that might cause client anxiety Correct Ans - A. Attempting to increase the clients' self-motivation A nurse is reinforcing teaching with a client who is using a patient-controlled analgesia (PA) pump to deliver morphine for pain management. Which of the
following statements should the nurse identify as an indication that the client
understands the instructions?
C A. "l'Il limit pushing the button so I don't get an overdose."
B. "If I push the button and still have pain after 2 minutes, I'll push it again."
C. "I'll ask my niece to push the button when I am sleeping."
D. "I can still use my TENS unit even though I'm pushing the PCA button." Correct Ans - D. "I can still use my TENS unit even though I'm pushing the PCA button."
A nurse is caring for a client who had a stroke and is at risk of falling. Which of the following actions should the nurse take?
A. Assign the client to a private room
B. Keep 4 side rails up while the client is in bed
C. Monitor the client at least once every hour
D. Request a PRN prescription for restraints Correct Ans - C. Monitor the client at least once every hour
A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room, the nurse discovers client is unresponsive to verbal or painful stimuli, has no respirations, and is pulseless. Which of the following actions should the nurse take first?
A. Start chest compressions
B. Provide breaths with a manual resuscitation bag
C. Administer oxygen
D. Establish an airway Correct Ans - A. Start chest compressions
A nurse is collecting data from a client. Which of the following statements by the nurse reflects the communication technique of clarifying?
A. "Now that we have talked about your medications, let's talk about your pain."
B. "Are you having other symptoms?"
C. "It sounds like your pain is intermittent."
D. "It seems as though you have really had a rough time these past few weeks." Correct Ans - C. "It sounds like your pain is intermittent."
A nurse is obtaining the blood pressure in a client's lower extremity. Which of
the following actions should the nurse take?
A. Auscultate for the blood pressure at the dorsalis pedis artery
B. Measure the blood pressure with the client sitting on the side of the bed
C. Place the cuff 7.6 cm (3 in) above the popliteal artery
D. Place the bladder of the cuff over the posterior aspect of the thigh Correct Ans - D. Place the bladder of the cuff over the posterior aspect of the thigh A nurse is reinforcing teaching with a preschooler about how to use a metered-dose inhaler. Which of the following methods should the nurse use during this instructional session?
A. A simple demonstration of inhaler use
B. A discussion of health problems
C. Collaboration in instruction
D. Mutual goal-setting Correct Ans - A. A simple demonstration of inhaler use
A nurse is reinforcing teaching for a client who has a new prescription for home oxygen therapy. Which of the following instructions should the nurse include?
A. Do not use any electrical devices when receiving oxygen
B. Keep the oxygen tank lying on the floor when there is any risk of knocking it over
C. Do not use any materials containing oil or alcohol when using oxygen
D. Use synthetic blankets and clothing when using oxygen Correct Ans - C. Do not use any materials containing oil or alcohol when using oxygen
A nurse is caring for a client who has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse
take first?
A. Apply a fecal collection system
B. Apply a barrier cream
C. Cleanse and dry the area
D. Check the client's perineum Correct Ans - D. Check the client's perineum
A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first?
A. Provide the client with a glass of water
B. Assist the client into a sitting position
C. Explain the procedure to the client
D. Measure the length of tubing to be inserted Correct Ans - C. Explain the
procedure to the client
A nurse is preparing to measure a client's blood pressure with a sphygmomanometer and a stethoscope. Which of the following actions should the nurse take?
A. Wrap the cuff loosely around the client's arm
B. Use a cuff with a bladder that encircles 60% of the client's upper arm
C. Place the cuff so its lower edge is 1.3 cm (0.5 in) above the antecubital space
D. Have the client place both feet flat on the floor Correct Ans - D. Have the client place both feet flat on the floor A nurse is reinforcing teaching with a client about how to obtain a capillary finger-stick blood sample. Which of the following actions by the client requires the nurse to intervene?
A. Elevates the finger above heart level
B. Rubs the fingertip with an alcohol pad
C. Punctures the side of the fingertip
D. Wraps the finger in a warm cloth Correct Ans - A. Elevates the finger above heart level
A nurse is collecting data from a client who has fluid-volume excess. Which of the following findings should the nurse expect?
A. Crackles in the lung fields
B. Flat neck veins
C. Postural hypotension
D. Dark yellow urine Correct Ans - A. Crackles in the lung fields
A nurse is caring for a client who states that she does not want to get out of bed due to pain from arthritis. Which of the following actions should the nurse take?
A. Tell the client the provider does not want her to remain in bed
B. Allow the client to remain in bed until her pain subsides
C. Instruct the family to perform ADLs for the client
D. Advise the client to perform range-of-motion exercises while in bed Correct Ans - D. Advise the client to perform range-of-motion exercises while in bed
A nurse is administering 3 liquid medications through a client's nasogastric tube. Which of the following actions should the nurse take?
A. Position the head of the client's bed at 15 degrees®
B. Mix the medications together in a medication cup
C. Pour the medications into the enteral formula container
D. Flush the tube with water before and after instilling each medication Correct Ans - D. Flush the tube with water before and after instilling each medication
A nurse enters a client's room and finds the client sitting on the floor and leaning against the side of the bed. The client states she slipped while getting out of bed. Which of the following actions should the nurse take first?
A. Complete an incident report
B. Check the client for injuries
C. Make sure the client has skid-free footwear
D. Remind the client to ask for help with getting out of bed Correct Ans - B. Check the client for injuries
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