CMS MedSurg Exam
A nurse is assisting with the plan of care for a client who has aspiration pneumonia and hypoxia. Which
of the following actions should the nurse plan to take?
A. Apply petroleum jelly to the client's nares.
B. Initiate fall precautions.
C. Implement contact precautions.
D. Maintain the client in a supine position. ANS: B. Initiate fall precautions.
A nurse is caring for an older adult client immediately following a bronchoscopy with biopsy. Which of
the following is the priority action the nurse should take?
A. Document sputum color and consistency.
B. Check for a gag reflex.
C. Offer ice chips.
D. Instruct the client to gargle with warm saline. ANS: B. Check for gag reflex.
A nurse is reinforcing health promotion education at a community health fair. Which of the following
statements by attendees indicates understanding of the teaching?
A. "I will examine my breasts a week after each menstrual period."
B. "I should get a hepatitis B vaccine on a yearly basis."
C. "I do my testicular self-exam every 6 months without fail."
D. "The flu shot I received last year will last me for 2 years." ANS: A. "I will examine my breasts a week
after each menstrual period."
,A nurse in a long-term care facility is collecting data from an older adult client. Which of the following
findings indicates that the client might be dehydrated?
A. Cool, clammy skin
B. Decrease in pulse rate
C. increase in blood pressure
D. Recent onset of confusion ANS: D. Recent onset of confusion
A nurse is collecting data from a client who had a long arm cast applied 2 hr ago. Which of the following
findings of the affected extremity should the nurse report to the provider immediately?
A. The client's fingers are cool to the touch.
B. The client's capillary refill is 3 seconds.
C. The client reports Increased pain at the area of the fracture.
D. The client reports severe itching under the cast. ANS: A. The client's fingers are cool to the touch.
A nurse in a long-term care unit is assisting in the care of a client who has Alzheimer's disease. Which of
the following actions should the nurse take?
A. Alternate the client's daily routine
B. Keep the lights dimmed.
C. Raise the four side rails on the client's bed.
D. Participate in reminiscence therapy with the client. ANS: D. Participate in reminiscence therapy with
the client.
A nurse is caring for a client who is postoperative following a right radical mastectomy. Which of the
following actions should the nurse take to prevent the development of lymphedema?
,A. Limit range of-motion exercises with the affected arm.
B. Use the client's left arm to obtain blood samples.
C. Keep both arms below the level of the client's heart.
D. Obtain blood pressure readings using the client's right arm. ANS: B. Use the client's left arm to obtain
blood samples.
A nurse is assisting a provider with removing a client's lower-leg cast. Which of the following statements
by the nurse is appropriate?
A. "You can expect your leg muscles to look a little swollen."
B. "You should avoid elevating your leg while sitting"
C. "You should hold still to prevent injury to your skin."
D. "You can expect to feel pressure when we cut the cast." ANS: D. "You can expect to feel pressure
when we cut the cast."
A nurse on a medical-surgical unit is caring for an older adult client who has developed sepsis due to a
urinary tract infection. A member of the client's family tells the nurse not to perform any "heroic
measures" to keep the client alive. Which of the following responses by the nurse is appropriate?
A. "The client's condition is not critical enough to discuss these issues."
B. "Let me check the client's medical record for advance directives."
C. "You should contact the client's attorney to document your wishes legally."
D. "Why do you believe treatment would not benefit the client?" ANS: B. "Let me check the client's
medical record for advance directives."
A nurse is monitoring a client who is receiving intravenous fluids. Which of the following findings
indicates a fluid volume excess? (Select all that apply)
, A. Bradycardia
B. Flat neck veins
C. Weight gain
D. Hypertension
E. Dyspnea ANS: C. Weight gain
D. Hypertension
E. Dyspnea
A nurse is caring for a client who is postoperative following a total thyroidectomy for hyperthyroidism.
Which of the following findings should the nurse identify as the priority?
A. Oral temperature 39° C (102.2° F)
B. Report of a sore throat
C. Serum calcium level 9.2 mg/dL
D. Moderate amount of sérosanguíneous drainage on dressings. ANS: A. Oral temperature 39° C (102.2°
F)
A nurse is reinforcing teaching about a heart-healthy diet with a client. Which of the following
statements by the client indicates that the teaching was effective?
A. "I will increase my intake of lean red meat."
B. "I will eat chicken as my source of fiber."
C. "I will use skim milk as my source of dairy."
D. "I will increase my servings of canned vegetables." ANS: A. "I will increase my intake of lean red
meat."
A nurse is assisting with the plan of care for a client who has aspiration pneumonia and hypoxia. Which
of the following actions should the nurse plan to take?
A. Apply petroleum jelly to the client's nares.
B. Initiate fall precautions.
C. Implement contact precautions.
D. Maintain the client in a supine position. ANS: B. Initiate fall precautions.
A nurse is caring for an older adult client immediately following a bronchoscopy with biopsy. Which of
the following is the priority action the nurse should take?
A. Document sputum color and consistency.
B. Check for a gag reflex.
C. Offer ice chips.
D. Instruct the client to gargle with warm saline. ANS: B. Check for gag reflex.
A nurse is reinforcing health promotion education at a community health fair. Which of the following
statements by attendees indicates understanding of the teaching?
A. "I will examine my breasts a week after each menstrual period."
B. "I should get a hepatitis B vaccine on a yearly basis."
C. "I do my testicular self-exam every 6 months without fail."
D. "The flu shot I received last year will last me for 2 years." ANS: A. "I will examine my breasts a week
after each menstrual period."
,A nurse in a long-term care facility is collecting data from an older adult client. Which of the following
findings indicates that the client might be dehydrated?
A. Cool, clammy skin
B. Decrease in pulse rate
C. increase in blood pressure
D. Recent onset of confusion ANS: D. Recent onset of confusion
A nurse is collecting data from a client who had a long arm cast applied 2 hr ago. Which of the following
findings of the affected extremity should the nurse report to the provider immediately?
A. The client's fingers are cool to the touch.
B. The client's capillary refill is 3 seconds.
C. The client reports Increased pain at the area of the fracture.
D. The client reports severe itching under the cast. ANS: A. The client's fingers are cool to the touch.
A nurse in a long-term care unit is assisting in the care of a client who has Alzheimer's disease. Which of
the following actions should the nurse take?
A. Alternate the client's daily routine
B. Keep the lights dimmed.
C. Raise the four side rails on the client's bed.
D. Participate in reminiscence therapy with the client. ANS: D. Participate in reminiscence therapy with
the client.
A nurse is caring for a client who is postoperative following a right radical mastectomy. Which of the
following actions should the nurse take to prevent the development of lymphedema?
,A. Limit range of-motion exercises with the affected arm.
B. Use the client's left arm to obtain blood samples.
C. Keep both arms below the level of the client's heart.
D. Obtain blood pressure readings using the client's right arm. ANS: B. Use the client's left arm to obtain
blood samples.
A nurse is assisting a provider with removing a client's lower-leg cast. Which of the following statements
by the nurse is appropriate?
A. "You can expect your leg muscles to look a little swollen."
B. "You should avoid elevating your leg while sitting"
C. "You should hold still to prevent injury to your skin."
D. "You can expect to feel pressure when we cut the cast." ANS: D. "You can expect to feel pressure
when we cut the cast."
A nurse on a medical-surgical unit is caring for an older adult client who has developed sepsis due to a
urinary tract infection. A member of the client's family tells the nurse not to perform any "heroic
measures" to keep the client alive. Which of the following responses by the nurse is appropriate?
A. "The client's condition is not critical enough to discuss these issues."
B. "Let me check the client's medical record for advance directives."
C. "You should contact the client's attorney to document your wishes legally."
D. "Why do you believe treatment would not benefit the client?" ANS: B. "Let me check the client's
medical record for advance directives."
A nurse is monitoring a client who is receiving intravenous fluids. Which of the following findings
indicates a fluid volume excess? (Select all that apply)
, A. Bradycardia
B. Flat neck veins
C. Weight gain
D. Hypertension
E. Dyspnea ANS: C. Weight gain
D. Hypertension
E. Dyspnea
A nurse is caring for a client who is postoperative following a total thyroidectomy for hyperthyroidism.
Which of the following findings should the nurse identify as the priority?
A. Oral temperature 39° C (102.2° F)
B. Report of a sore throat
C. Serum calcium level 9.2 mg/dL
D. Moderate amount of sérosanguíneous drainage on dressings. ANS: A. Oral temperature 39° C (102.2°
F)
A nurse is reinforcing teaching about a heart-healthy diet with a client. Which of the following
statements by the client indicates that the teaching was effective?
A. "I will increase my intake of lean red meat."
B. "I will eat chicken as my source of fiber."
C. "I will use skim milk as my source of dairy."
D. "I will increase my servings of canned vegetables." ANS: A. "I will increase my intake of lean red
meat."
