PN ADULT MEDICAL SURGICAL CMS EXAM
QUESTIONS AND CORRECT DETAILED SOLUIONS
WITH RATIONALES
A nurse is caring for a client who has a new prescription for nitroglycerin. The nurse should
monitor for which of the following adverse effects of the medication?
Nocturia
Increased saliva production
Flushing
Fever --CORRECT ANSWER--Flushing
Rationale:
nitroglycerin is a vaso-dilator. When vaso-dilators too well, fluid start sipping out and
causing flushing
A nurse is preparing to obtain a postprandial blood glucose level from a client who has
diabetes mellitus. Which of the following actions should the nurse take?
a) Apply the first drop of blood to the test strip.
b) Clean the client's finger with hexachlorophene.
c) Prick the central tip of the client's finger.
d) Hold the client's finger in a dependent position. --CORRECT ANSWER--D. Hold the
client's finger in a dependent
position.
Rationale:
The nurse should clean the client's finger with an alcohol swab and prick the side of the
finger, not the central tip, to obtain a postprandial blood glucose level.
Page 1 of 230
,The nurse should not apply the first drop of blood to the test strip since the alcohol could
cause false reading.
Hexachlorophene is not recommended for cleaning the client's finger as it can cause tissue
damage.
TEST
A nurse is reinforcing teaching with a client about breast self-examinations. Which of the
following statements by the client indicates an understanding of the teaching?
a) "It is common for one breast to be larger than the other."
b) "It is common for the skin on my breasts to dimple."
c) "I will perform breast exams the day my period begins."
d) "I will perform breast exams every other month." --CORRECT ANSWER--A. "It is
common for one breast to be larger than
the other."
Rationale:
It is normal to have asymmetrical breasts, usually, the left breast is bigger than the right.
This is because of the difference in the percentage of breast tissues and fatty tissues, that's
why they react differently to hormonal changes.
"Dimpling on the skin on breasts is NOT common" Physician consultation should be taken
regarding this as it can be a sign of breast cancer.
"Self-breast exams are recommended to be performed after a week when the period starts."
The rest of the month breasts reamain tender due to hormone fluctuation.
"Self-Breast exams should be performed every month." For women in reproductive age
usually after a week when the period starts and at the same day of every month for women
who have attained menopause.
Page 2 of 230
,A nurse is caring for a client who is taking lithium and reports persistent nausea and vomiting
for 2 days. Which of the following laboratory values should the nurse report to the provider?
a) Potassium 4.0 mEq/L
b) Lithium 0.9 mEq/L
c) BUN 12 mg/dL
d) Sodium 132 mEq/L --CORRECT ANSWER--D. Sodium 132 mEq/L
Rationale:
The nurse should identify that a sodium level of 132 mEq/L is not within the expected
reference range of 136 to 145 mEq/L. This finding indicates hyponatremia, which can lead to
lithium accumulation and places the client at risk for lithium toxicity. The nurse should report
this finding to the provider.
A nurse is caring for a client who has cancer and has a WBC count of 4,000/mm3. Which of
the following
actions should the nurse take?
a) Cleanse the client's toothbrush with hydrogen peroxide.
b) Instruct the client to use a disposable razor to shave.
c) Decrease the client's protein intake.
d) Encourage the client to eat unpasteurized dairy products. --CORRECT ANSWER--A.
Cleanse the client's toothbrush with hydrogen peroxide.
Rationale:
A WBC count of 4,000/mm3 is considered low and is known as leukopenia. A low WBC
count can be caused by cancer or cancer treatment. The nurse should instruct the client to
cleanse their toothbrush with hydrogen peroxide. People with leukemia or leukopenia should
avoid using disposable razors, which can cause cuts and bleeding that can lead to infections.
Instead, they recommend using an electric razor to reduce the risk of injury. Encouraging the
client to eat unpasteurized dairy products is not recommended as they can contain harmful
bacteria that can cause infections. Decreasing the client's protein intake is not recommended
as protein is important for wound healing and immune function
Page 3 of 230
, TEST
A nurse enters a client's room and sees smoke coming from the bathroom. Which of the
following actions should the nurse take first?
a) Activate the fire alarm system.
b) Use a fire extinguisher at the source of the
smoke.
c) Assist the client to a nearby common area.
d) Close the doors to the room and to the
bathroom. --CORRECT ANSWER--C. Assist the client to a nearby common area.
Rationale:
use
Rescue
Alarm
Contain
Extinguish
TEST
A nurse is contributing to the plan of care for a client who reports difficulty eating due to
chronic arthritis. Which of the following interventions should the nurse include in the plan?
a) Apply foam handles to the client's eating utensils.
b) Obtain a referral for physical therapy.
c) Have an assistive personnel feed the client.
d) Ask the provider for a prescription for a pureed diet. --CORRECT ANSWER--A. Apply
foam handles to the client's eating utensils.
Rationale:
Page 4 of 230
QUESTIONS AND CORRECT DETAILED SOLUIONS
WITH RATIONALES
A nurse is caring for a client who has a new prescription for nitroglycerin. The nurse should
monitor for which of the following adverse effects of the medication?
Nocturia
Increased saliva production
Flushing
Fever --CORRECT ANSWER--Flushing
Rationale:
nitroglycerin is a vaso-dilator. When vaso-dilators too well, fluid start sipping out and
causing flushing
A nurse is preparing to obtain a postprandial blood glucose level from a client who has
diabetes mellitus. Which of the following actions should the nurse take?
a) Apply the first drop of blood to the test strip.
b) Clean the client's finger with hexachlorophene.
c) Prick the central tip of the client's finger.
d) Hold the client's finger in a dependent position. --CORRECT ANSWER--D. Hold the
client's finger in a dependent
position.
Rationale:
The nurse should clean the client's finger with an alcohol swab and prick the side of the
finger, not the central tip, to obtain a postprandial blood glucose level.
Page 1 of 230
,The nurse should not apply the first drop of blood to the test strip since the alcohol could
cause false reading.
Hexachlorophene is not recommended for cleaning the client's finger as it can cause tissue
damage.
TEST
A nurse is reinforcing teaching with a client about breast self-examinations. Which of the
following statements by the client indicates an understanding of the teaching?
a) "It is common for one breast to be larger than the other."
b) "It is common for the skin on my breasts to dimple."
c) "I will perform breast exams the day my period begins."
d) "I will perform breast exams every other month." --CORRECT ANSWER--A. "It is
common for one breast to be larger than
the other."
Rationale:
It is normal to have asymmetrical breasts, usually, the left breast is bigger than the right.
This is because of the difference in the percentage of breast tissues and fatty tissues, that's
why they react differently to hormonal changes.
"Dimpling on the skin on breasts is NOT common" Physician consultation should be taken
regarding this as it can be a sign of breast cancer.
"Self-breast exams are recommended to be performed after a week when the period starts."
The rest of the month breasts reamain tender due to hormone fluctuation.
"Self-Breast exams should be performed every month." For women in reproductive age
usually after a week when the period starts and at the same day of every month for women
who have attained menopause.
Page 2 of 230
,A nurse is caring for a client who is taking lithium and reports persistent nausea and vomiting
for 2 days. Which of the following laboratory values should the nurse report to the provider?
a) Potassium 4.0 mEq/L
b) Lithium 0.9 mEq/L
c) BUN 12 mg/dL
d) Sodium 132 mEq/L --CORRECT ANSWER--D. Sodium 132 mEq/L
Rationale:
The nurse should identify that a sodium level of 132 mEq/L is not within the expected
reference range of 136 to 145 mEq/L. This finding indicates hyponatremia, which can lead to
lithium accumulation and places the client at risk for lithium toxicity. The nurse should report
this finding to the provider.
A nurse is caring for a client who has cancer and has a WBC count of 4,000/mm3. Which of
the following
actions should the nurse take?
a) Cleanse the client's toothbrush with hydrogen peroxide.
b) Instruct the client to use a disposable razor to shave.
c) Decrease the client's protein intake.
d) Encourage the client to eat unpasteurized dairy products. --CORRECT ANSWER--A.
Cleanse the client's toothbrush with hydrogen peroxide.
Rationale:
A WBC count of 4,000/mm3 is considered low and is known as leukopenia. A low WBC
count can be caused by cancer or cancer treatment. The nurse should instruct the client to
cleanse their toothbrush with hydrogen peroxide. People with leukemia or leukopenia should
avoid using disposable razors, which can cause cuts and bleeding that can lead to infections.
Instead, they recommend using an electric razor to reduce the risk of injury. Encouraging the
client to eat unpasteurized dairy products is not recommended as they can contain harmful
bacteria that can cause infections. Decreasing the client's protein intake is not recommended
as protein is important for wound healing and immune function
Page 3 of 230
, TEST
A nurse enters a client's room and sees smoke coming from the bathroom. Which of the
following actions should the nurse take first?
a) Activate the fire alarm system.
b) Use a fire extinguisher at the source of the
smoke.
c) Assist the client to a nearby common area.
d) Close the doors to the room and to the
bathroom. --CORRECT ANSWER--C. Assist the client to a nearby common area.
Rationale:
use
Rescue
Alarm
Contain
Extinguish
TEST
A nurse is contributing to the plan of care for a client who reports difficulty eating due to
chronic arthritis. Which of the following interventions should the nurse include in the plan?
a) Apply foam handles to the client's eating utensils.
b) Obtain a referral for physical therapy.
c) Have an assistive personnel feed the client.
d) Ask the provider for a prescription for a pureed diet. --CORRECT ANSWER--A. Apply
foam handles to the client's eating utensils.
Rationale:
Page 4 of 230
