Complex CMS Question & Answers
,1. A nurse is reviewing the medical record of a client who is scheduled for a CTscan with
contrast media. Which of the following medications should the nurse instruct the client to
withhold for 48 hr following the procedure?
a. Clopidogrel
b. Furosemide
c. Carvedilol
d. Metformin
2. A nurse is providing discharge teaching to a client who has heart failure and instructs him
to limit sodium intake to 2 g per day. Which of the following statements by the client
indicates an understanding of the teaching?
a. “I can have mayonnaise on my sandwiches.”
b. “I can season my food with garlic and onion salts.”
c. “I can drink vegetable juice with a meal.”
d. “I can have a frozen fruit juice bar for dessert.”
3. A nurse is assessing a client who is receiving valsartan to treat heart failure. Which of
the following findings should the nurse identify as an indication that the medication is
effective?
a. Increased potassium level
b. Increased heart rate
c. Decreased urinary output
d. Decreased blood pressure
4. A nurse is caring for a client who has cervical cancer and a sealed radiation implant.
Which of the following actions should the nurse take?
a. Attach a dosimeter badge to the client’s gown
b. Leave unused equipment in the client’s room until discharge
c. Place long-handled forceps at the client’s bedside
d. Move the client’s soiled linens to a designated container outside the room
5. A nurse is assessing the pain status of a group of clients. Which of the following
findings indicate a client is experiencing referred pain?
a. A client who has angina reports substernal chest pain
b. A client who is postoperative reports incisional pain
c. A client who has pancreatitis reports pain in the left shoulder
d. A client who has peritonitis reports generalized abdominal pain
6. A nurse is caring for a client who is postoperative following a partial thyroidectomy.
Which of the following findings is the priority for the nurse to report to the provider?
a. High pitched sound on inspiration
b. Hypoactive bowel sounds
c. Loose tracheal secretions
d. Client report of pain at the incision site
,7. 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 the alternative
therapy?
a. Urticaria
b. Lymphedema
c. Mouth sores
d. Headaches
8. 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?
a. “I will empty my bag when it is full.”
b. “I will eat a high-fiber diet.”
c. “I expect my stools to be loose.”
d. “I will take a laxative when I’m constipated.”
9. A nurse is caring for a client who has bladder cancer and WBC count of 900/mm.
Which of the following actions should the nurse take?
a. Use contact isolation while providing care
b. Instruct the client to avoid eating raw fruit
c. Apply pressure to venipuncture sites of 10 minutes
d. Move the client to a negative pressure room
10. A nurse is providing discharge teaching to a client who has chronic urinary tract
infection. The client has a prescription for ciprofloxacin 250 mg PO twice daily.
Which of the following instructions should the nurse include in the teaching?
a. Monitor heart rate once daily
b. Drink 2 to 3 L of fluids daily
c. Take a laxative to prevent constipation
d. Take an antacid 30 minutes before taking the medication
11. A nurse is performing a cranial nerve assessment on a client following a head injury.
Which of the following findings should the nurse expect if the client has impaired
function of the vestibulocochlear nerve (cranial nerve VIII)?
a. Deviation of the tongue from midline
b. Loss of peripheral vision
c. Disequilibrium with movement
d. Instability to smell
12. A nurse is caring for a client who has IV in the left forearm and whose infusion pump has
alarmed several times. Which of the following actions should the nurse take first?
a. Flush the IV catheter
b. Reposition the client’s arm
c. Ensure the tubing connections are secure
d. Check the IV site for redness
, 13. A nurse is caring for a client who has severe burn injury. The nurse should recognize
which of the following as an indication of hypovolemic shock?
a. PaCO2 37 mm Hg
b. Potassium 5.2 mEq/L
c. Urine output 45 mL/hr
d. Capillary refill 1.5 seconds
14. A nurse is providing instructions about foot care for a client who has peripheral arterial
disease. The nurse should identify which of the following statements by the client
indicates an understanding of the teaching?
a. “I rest in my recliner with my feet elevated for about an hour
every afternoon.”
b. “I apply a lubrication lotion to the cracked areas on the soles of my feet every
evening.”
c. “I use my heating pad on a low setting to keep my feet warm.”
d. “I soak my feet in hot water before trimming my toenails.”
15. A nurse is caring for a client who is taking digoxin 0.125 mg PO daily and is at risk for
developing digoxin toxicity. The nurse should monitor the client for an imbalance of
which of the following electrolytes because it can increase the risk for digoxin toxicity?
a. Calcium
b. Potassium
c. Magnesium
d. Phosphate
16. A nurse is monitoring a client who is receiving 2 units of packed RBCs. which of the
following manifestations indicates a hemolytic transfusion reaction?
a. Bradycardia
b. Chills
c. Back pain
d. Hypertension
17. A nurse is reviewing the medical record of a client who has pneumonia. Which of
the following serum laboratory values should the nurse expect?
a. WBC count 15,000/mm
b. Sodium 130 mg/dL
c. BUN 8 mg/dL
d. Hematocrit 35%
18. A nurse is preparing to assist the provider with thoracentesis for a client who has a left
pleural effusion. Which of the following interventions is the priority for the nurse?
a. Determine whether the client has an allergy to local
anesthetics b. Reinforce the importance of lying still during the
procedure
c. Administer a sedative medication
d. Describe the sensations the client will feel during the procedure
,1. A nurse is reviewing the medical record of a client who is scheduled for a CTscan with
contrast media. Which of the following medications should the nurse instruct the client to
withhold for 48 hr following the procedure?
a. Clopidogrel
b. Furosemide
c. Carvedilol
d. Metformin
2. A nurse is providing discharge teaching to a client who has heart failure and instructs him
to limit sodium intake to 2 g per day. Which of the following statements by the client
indicates an understanding of the teaching?
a. “I can have mayonnaise on my sandwiches.”
b. “I can season my food with garlic and onion salts.”
c. “I can drink vegetable juice with a meal.”
d. “I can have a frozen fruit juice bar for dessert.”
3. A nurse is assessing a client who is receiving valsartan to treat heart failure. Which of
the following findings should the nurse identify as an indication that the medication is
effective?
a. Increased potassium level
b. Increased heart rate
c. Decreased urinary output
d. Decreased blood pressure
4. A nurse is caring for a client who has cervical cancer and a sealed radiation implant.
Which of the following actions should the nurse take?
a. Attach a dosimeter badge to the client’s gown
b. Leave unused equipment in the client’s room until discharge
c. Place long-handled forceps at the client’s bedside
d. Move the client’s soiled linens to a designated container outside the room
5. A nurse is assessing the pain status of a group of clients. Which of the following
findings indicate a client is experiencing referred pain?
a. A client who has angina reports substernal chest pain
b. A client who is postoperative reports incisional pain
c. A client who has pancreatitis reports pain in the left shoulder
d. A client who has peritonitis reports generalized abdominal pain
6. A nurse is caring for a client who is postoperative following a partial thyroidectomy.
Which of the following findings is the priority for the nurse to report to the provider?
a. High pitched sound on inspiration
b. Hypoactive bowel sounds
c. Loose tracheal secretions
d. Client report of pain at the incision site
,7. 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 the alternative
therapy?
a. Urticaria
b. Lymphedema
c. Mouth sores
d. Headaches
8. 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?
a. “I will empty my bag when it is full.”
b. “I will eat a high-fiber diet.”
c. “I expect my stools to be loose.”
d. “I will take a laxative when I’m constipated.”
9. A nurse is caring for a client who has bladder cancer and WBC count of 900/mm.
Which of the following actions should the nurse take?
a. Use contact isolation while providing care
b. Instruct the client to avoid eating raw fruit
c. Apply pressure to venipuncture sites of 10 minutes
d. Move the client to a negative pressure room
10. A nurse is providing discharge teaching to a client who has chronic urinary tract
infection. The client has a prescription for ciprofloxacin 250 mg PO twice daily.
Which of the following instructions should the nurse include in the teaching?
a. Monitor heart rate once daily
b. Drink 2 to 3 L of fluids daily
c. Take a laxative to prevent constipation
d. Take an antacid 30 minutes before taking the medication
11. A nurse is performing a cranial nerve assessment on a client following a head injury.
Which of the following findings should the nurse expect if the client has impaired
function of the vestibulocochlear nerve (cranial nerve VIII)?
a. Deviation of the tongue from midline
b. Loss of peripheral vision
c. Disequilibrium with movement
d. Instability to smell
12. A nurse is caring for a client who has IV in the left forearm and whose infusion pump has
alarmed several times. Which of the following actions should the nurse take first?
a. Flush the IV catheter
b. Reposition the client’s arm
c. Ensure the tubing connections are secure
d. Check the IV site for redness
, 13. A nurse is caring for a client who has severe burn injury. The nurse should recognize
which of the following as an indication of hypovolemic shock?
a. PaCO2 37 mm Hg
b. Potassium 5.2 mEq/L
c. Urine output 45 mL/hr
d. Capillary refill 1.5 seconds
14. A nurse is providing instructions about foot care for a client who has peripheral arterial
disease. The nurse should identify which of the following statements by the client
indicates an understanding of the teaching?
a. “I rest in my recliner with my feet elevated for about an hour
every afternoon.”
b. “I apply a lubrication lotion to the cracked areas on the soles of my feet every
evening.”
c. “I use my heating pad on a low setting to keep my feet warm.”
d. “I soak my feet in hot water before trimming my toenails.”
15. A nurse is caring for a client who is taking digoxin 0.125 mg PO daily and is at risk for
developing digoxin toxicity. The nurse should monitor the client for an imbalance of
which of the following electrolytes because it can increase the risk for digoxin toxicity?
a. Calcium
b. Potassium
c. Magnesium
d. Phosphate
16. A nurse is monitoring a client who is receiving 2 units of packed RBCs. which of the
following manifestations indicates a hemolytic transfusion reaction?
a. Bradycardia
b. Chills
c. Back pain
d. Hypertension
17. A nurse is reviewing the medical record of a client who has pneumonia. Which of
the following serum laboratory values should the nurse expect?
a. WBC count 15,000/mm
b. Sodium 130 mg/dL
c. BUN 8 mg/dL
d. Hematocrit 35%
18. A nurse is preparing to assist the provider with thoracentesis for a client who has a left
pleural effusion. Which of the following interventions is the priority for the nurse?
a. Determine whether the client has an allergy to local
anesthetics b. Reinforce the importance of lying still during the
procedure
c. Administer a sedative medication
d. Describe the sensations the client will feel during the procedure
