CMSRN Medical-surgical nursing
certification validating comprehensive adult
care knowledge, clinical judgment, patient
safety, and evidence-based practice.
Question 1
A 68-year-old patient with heart failure is scheduled to receive digoxin 0.25 mg
orally. Current assessment reveals heart rate 58 bpm, blood pressure 128/78
mmHg, and serum potassium 3.6 mEq/L. Which finding requires withholding the
medication?
A) Blood pressure 128/78 mmHg
B) Heart rate 58 bpm
C) Serum potassium 3.6 mEq/L
D) Age 68 years
Rationale: The serum potassium level of 3.6 mEq/L is within normal range (3.5-
5.0 mEq/L) and does not require withholding digoxin. However, digoxin is
typically held for heart rates below 60 bpm in adults. A heart rate of 58 bpm is
below this threshold and warrants holding the medication and notifying the
provider. The blood pressure is within acceptable range, and age alone is not a
contraindication.
Question 2
A patient with diabetes and chronic renal failure develops fever (101.2°F/38.4°C),
tachycardia (112 bpm), and warm flushed skin two days after central line insertion.
Which intervention should be implemented FIRST?
A) Administer antipyretics
B) Obtain blood cultures from the central line and a peripheral site
C) Remove the central line immediately
D) Administer broad-spectrum antibiotics
,Rationale: The patient is exhibiting signs of a central line-associated bloodstream
infection (CLABSI). The priority intervention is to obtain blood cultures from both
the central line and a peripheral site before initiating antibiotics to identify the
causative organism. Removing the line without cultures may compromise the
diagnostic workup. Antipyretics and antibiotics are important but should follow
culture collection.
Question 3
A 24-year-old patient with a closed femur fracture from a motor vehicle accident
develops respiratory distress, altered mental status, and hypoxia 48 hours after
injury. Which assessment finding is most characteristic of fat embolus syndrome?
A) Petechial rash on the chest and axillae
B) Bilateral crackles in the lung bases
C) Jugular venous distension
D) Peripheral edema
Rationale: Fat embolus syndrome is characterized by the classic triad of
hypoxemia, neurologic changes, and petechial rash, which typically appears on the
chest, axillae, and conjunctivae within 24-72 hours of injury. The petechial rash
results from fat globules lodging in the capillaries and is a hallmark finding.
Crackles, JVD, and peripheral edema are more consistent with fluid overload or
heart failure.
Question 4
A patient with widespread breast cancer has developed bone metastases throughout
the spine and pelvis, experiencing worsening pain and limited mobility. Which
approach best reflects appropriate palliative care management?
A) Focus on pain management, functional support, and quality of life
B) Continue aggressive chemotherapy to treat the metastases
C) Limit interventions to comfort measures only
D) Refer to hospice care immediately
Rationale: Palliative care focuses on improving quality of life through
comprehensive symptom management, including pain control, functional support,
and psychosocial care, regardless of the disease stage. It can be provided
,concurrently with curative or life-prolonging treatments. Palliative care is not
limited to comfort measures only and does not require immediate hospice referral.
Question 5
A hospitalized patient reports constant worry, refuses diagnostic tests, experiences
nausea and insomnia, and states "everything will go wrong." Which assessment
describes this response?
A) Depression
B) Anxiety
C) Delirium
D) Somatization
Rationale: The patient is exhibiting classic signs of anxiety, including excessive
worry, avoidance of procedures, somatic symptoms (nausea, insomnia), and
catastrophic thinking ("everything will go wrong"). While depression may coexist,
the prominent features here are worry and fear rather than pervasive sadness or
anhedonia. Delirium would involve acute cognitive changes, and somatization
involves physical symptoms without identifiable medical cause.
Question 6
A patient arrives with temperature 101.8°F (38.8°C), heart rate 110 bpm, blood
pressure 88/54 mmHg, altered mental status, lactate 3.2 mmol/L, and white blood
cell count 16,000/mm³. What intervention takes highest priority?
A) Administer antipyretics
B) Initiate broad-spectrum antibiotics after blood cultures
C) Administer vasopressors
D) Obtain a STAT chest x-ray
Rationale: This patient is in septic shock (fever, tachycardia, hypotension, altered
mental status, elevated lactate, and leukocytosis). The Surviving Sepsis Campaign
guidelines recommend obtaining blood cultures before initiating broad-spectrum
antibiotics, with antibiotic administration as the priority intervention within the
first hour of recognition. Vasopressors may be needed after fluid resuscitation.
Antipyretics and imaging are secondary.
, Question 7
A stroke patient requires positioning interventions to optimize venous blood flow
from the brain. Which positioning strategy should the nurse implement?
A) Keep the head of the bed elevated to 30 degrees
B) Place the patient in Trendelenburg position
C) Keep the patient flat and supine
D) Position the patient on the affected side
Rationale: Elevating the head of the bed to 30 degrees promotes venous drainage
from the brain, reducing intracranial pressure and optimizing cerebral perfusion.
Trendelenburg positioning increases intracranial pressure and is contraindicated in
stroke patients. Keeping the patient flat may impede venous return and increase
ICP. Positioning on the affected side does not specifically address venous outflow.
Question 8
A patient presents to the emergency department 3 hours after developing acute left-
sided weakness, facial drooping, and speech difficulties. Which diagnostic test
should be obtained first to guide immediate treatment decisions?
A) Carotid ultrasound
B) Non-contrast computed tomography (CT) of the head
C) Magnetic resonance imaging (MRI) of the brain
D) Electroencephalogram (EEG)
Rationale: Non-contrast CT of the head is the initial imaging study of choice for
acute stroke to rapidly distinguish between ischemic and hemorrhagic stroke. This
distinction is critical because thrombolytic therapy (tPA) is contraindicated in
hemorrhagic stroke. The patient is within the 4.5-hour window for tPA
administration, making prompt CT essential. MRI takes longer and is not the first-
line study. Carotid ultrasound and EEG are not appropriate initial studies.
Question 9
A patient is admitted with acute pancreatitis. Which laboratory finding is most
specific for this condition?
A) Elevated white blood cell count
B) Elevated serum lipase
certification validating comprehensive adult
care knowledge, clinical judgment, patient
safety, and evidence-based practice.
Question 1
A 68-year-old patient with heart failure is scheduled to receive digoxin 0.25 mg
orally. Current assessment reveals heart rate 58 bpm, blood pressure 128/78
mmHg, and serum potassium 3.6 mEq/L. Which finding requires withholding the
medication?
A) Blood pressure 128/78 mmHg
B) Heart rate 58 bpm
C) Serum potassium 3.6 mEq/L
D) Age 68 years
Rationale: The serum potassium level of 3.6 mEq/L is within normal range (3.5-
5.0 mEq/L) and does not require withholding digoxin. However, digoxin is
typically held for heart rates below 60 bpm in adults. A heart rate of 58 bpm is
below this threshold and warrants holding the medication and notifying the
provider. The blood pressure is within acceptable range, and age alone is not a
contraindication.
Question 2
A patient with diabetes and chronic renal failure develops fever (101.2°F/38.4°C),
tachycardia (112 bpm), and warm flushed skin two days after central line insertion.
Which intervention should be implemented FIRST?
A) Administer antipyretics
B) Obtain blood cultures from the central line and a peripheral site
C) Remove the central line immediately
D) Administer broad-spectrum antibiotics
,Rationale: The patient is exhibiting signs of a central line-associated bloodstream
infection (CLABSI). The priority intervention is to obtain blood cultures from both
the central line and a peripheral site before initiating antibiotics to identify the
causative organism. Removing the line without cultures may compromise the
diagnostic workup. Antipyretics and antibiotics are important but should follow
culture collection.
Question 3
A 24-year-old patient with a closed femur fracture from a motor vehicle accident
develops respiratory distress, altered mental status, and hypoxia 48 hours after
injury. Which assessment finding is most characteristic of fat embolus syndrome?
A) Petechial rash on the chest and axillae
B) Bilateral crackles in the lung bases
C) Jugular venous distension
D) Peripheral edema
Rationale: Fat embolus syndrome is characterized by the classic triad of
hypoxemia, neurologic changes, and petechial rash, which typically appears on the
chest, axillae, and conjunctivae within 24-72 hours of injury. The petechial rash
results from fat globules lodging in the capillaries and is a hallmark finding.
Crackles, JVD, and peripheral edema are more consistent with fluid overload or
heart failure.
Question 4
A patient with widespread breast cancer has developed bone metastases throughout
the spine and pelvis, experiencing worsening pain and limited mobility. Which
approach best reflects appropriate palliative care management?
A) Focus on pain management, functional support, and quality of life
B) Continue aggressive chemotherapy to treat the metastases
C) Limit interventions to comfort measures only
D) Refer to hospice care immediately
Rationale: Palliative care focuses on improving quality of life through
comprehensive symptom management, including pain control, functional support,
and psychosocial care, regardless of the disease stage. It can be provided
,concurrently with curative or life-prolonging treatments. Palliative care is not
limited to comfort measures only and does not require immediate hospice referral.
Question 5
A hospitalized patient reports constant worry, refuses diagnostic tests, experiences
nausea and insomnia, and states "everything will go wrong." Which assessment
describes this response?
A) Depression
B) Anxiety
C) Delirium
D) Somatization
Rationale: The patient is exhibiting classic signs of anxiety, including excessive
worry, avoidance of procedures, somatic symptoms (nausea, insomnia), and
catastrophic thinking ("everything will go wrong"). While depression may coexist,
the prominent features here are worry and fear rather than pervasive sadness or
anhedonia. Delirium would involve acute cognitive changes, and somatization
involves physical symptoms without identifiable medical cause.
Question 6
A patient arrives with temperature 101.8°F (38.8°C), heart rate 110 bpm, blood
pressure 88/54 mmHg, altered mental status, lactate 3.2 mmol/L, and white blood
cell count 16,000/mm³. What intervention takes highest priority?
A) Administer antipyretics
B) Initiate broad-spectrum antibiotics after blood cultures
C) Administer vasopressors
D) Obtain a STAT chest x-ray
Rationale: This patient is in septic shock (fever, tachycardia, hypotension, altered
mental status, elevated lactate, and leukocytosis). The Surviving Sepsis Campaign
guidelines recommend obtaining blood cultures before initiating broad-spectrum
antibiotics, with antibiotic administration as the priority intervention within the
first hour of recognition. Vasopressors may be needed after fluid resuscitation.
Antipyretics and imaging are secondary.
, Question 7
A stroke patient requires positioning interventions to optimize venous blood flow
from the brain. Which positioning strategy should the nurse implement?
A) Keep the head of the bed elevated to 30 degrees
B) Place the patient in Trendelenburg position
C) Keep the patient flat and supine
D) Position the patient on the affected side
Rationale: Elevating the head of the bed to 30 degrees promotes venous drainage
from the brain, reducing intracranial pressure and optimizing cerebral perfusion.
Trendelenburg positioning increases intracranial pressure and is contraindicated in
stroke patients. Keeping the patient flat may impede venous return and increase
ICP. Positioning on the affected side does not specifically address venous outflow.
Question 8
A patient presents to the emergency department 3 hours after developing acute left-
sided weakness, facial drooping, and speech difficulties. Which diagnostic test
should be obtained first to guide immediate treatment decisions?
A) Carotid ultrasound
B) Non-contrast computed tomography (CT) of the head
C) Magnetic resonance imaging (MRI) of the brain
D) Electroencephalogram (EEG)
Rationale: Non-contrast CT of the head is the initial imaging study of choice for
acute stroke to rapidly distinguish between ischemic and hemorrhagic stroke. This
distinction is critical because thrombolytic therapy (tPA) is contraindicated in
hemorrhagic stroke. The patient is within the 4.5-hour window for tPA
administration, making prompt CT essential. MRI takes longer and is not the first-
line study. Carotid ultrasound and EEG are not appropriate initial studies.
Question 9
A patient is admitted with acute pancreatitis. Which laboratory finding is most
specific for this condition?
A) Elevated white blood cell count
B) Elevated serum lipase
