Fundamentals CMS Proctored Exam 2025/2026 -
NEW 100% Correct Questions & Verified Answer
1. A nurse enters a client’s room and finds the pulse oximeter reading 87%. Which
action should the nurse take first?
A) Increase the client’s oxygen flow rate
B) Check the probe placement on the client’s finger
C) Notify the provider immediately
D) Obtain an arterial blood gas sample
Answer: B
Rationale: Verify accuracy first; misplaced or poorly perfused probes give false
lows. Acting on an artifact can lead to unnecessary oxygen therapy (common
CMS trap).
2. The nurse is preparing to insert an indwelling urinary catheter. Which action best
reduces the risk of infection?
A) Use clean technique for the meatus and sterile gloves for insertion
B) Perform hand hygiene and don sterile gloves and maintain a sterile field
C) Wear clean gloves and lubricate the catheter tip with tap water
D) Insert the catheter while the client is in a semi-recumbent position
Answer: B
Rationale: Sterile technique throughout insertion is standard; hand hygiene plus
sterile gloves/equipment prevents pathogen introduction into the urethra.
3. A client is prescribed a newly ordered oral medication. The nurse notes the
medication is not in the electronic health record. Which action should the nurse
take first?
A) Give the medication and document it afterward
B) Hold the medication and verify the order with the prescriber
C) Ask the client if they have taken this drug before
D) Administer the medication and notify pharmacy later
Answer: B
Rationale: “Right order” is one of the six rights; giving an unverified drug violates
safe practice and is a classic CMS error.
4. A client on fall precautions attempts to get out of bed unassisted. Which
intervention is most appropriate?
A) Apply wrist restraints to keep the client in bed
B) Raise the bed to the highest position and lower side rails
, C) Place the bed in lowest position and keep call light within reach
D) Keep the room lights dim to promote rest
Answer: C
Rationale: Bed-low position minimizes injury risk if a fall occurs, and an
accessible call light supports safety; restraints are a last resort and require
orders.
5. The nurse is delegating morning hygiene care to an assistive personnel (AP).
Which instruction is most appropriate?
A) “Report any skin redness or areas of warmth to me.”
B) “Apply lotion to any open areas you notice.”
C) “Give the client a bed bath and don’t worry about documenting.”
D) “Use cold water to help stimulate circulation.”
Answer: A
Rationale: Assessment remains the nurse’s responsibility; instructing the AP to
report abnormalities keeps delegation within scope and supports early detection
of skin breakdown.
6. A postoperative client suddenly reports, “Something popped in my belly.” The
nurse notes eviscerated bowel protruding through the incision. Which action
should the nurse take first?
A) Apply sterile saline-soaked gauze and cover the area
B) Push the bowel back in and apply an abdominal binder
C) Offer oral fluids to prevent dehydration
D) Remove the staples to relieve tension
Answer: A
Rationale: Priority is to prevent desiccation and contamination of exposed bowel
with sterile, moist dressings while preparing for immediate surgical repair; never
reinsert organs at bedside.
7. A client’s morning blood glucose is 45 mg/dL. The client is alert but reports
feeling shaky. Which action should the nurse take first?
A) Give 15 g of oral glucose gel or 4 oz of juice
B) Start an IV and administer 50% dextrose
C) Recheck the glucose in 30 minutes without treating
D) Offer a high-protein snack like cheese
Answer: A
Rationale: Conscious hypoglycemia is treated with 15 g rapid-acting
carbohydrate orally; IV dextrose is reserved for altered mental status or inability
to swallow.
8. The nurse is preparing to apply a wrist restraint to an agitated client. Which
action is required?
, A) Secure the restraint to the side rail
B) Obtain a provider order and check circulation every 15 minutes
C) Tie the restraint with a square knot
D) Pad the foot pedals instead
Answer: B
Rationale: A provider order is mandatory, and circulation/distal neurovascular
checks every 15 min ensure safety; restraints must never be tied to side rails or
use square knots (slip knots are safer).
9. A client returns from surgery with a PCA pump. The nurse notes respirations
8/min and SpO₂ 89%. Which medication should the nurse prepare to administer?
A) Naloxone
B) Ketorolac
C) Ondansetron
D) Diphenhydramine
Answer: A
Rationale: Opioid-induced respiratory depression is reversed with naloxone; the
other drugs do not treat respiratory depression.
10. A client is receiving a continuous enteral feeding. Gastric residual volume is 275
mL. Which action should the nurse take first?
A) Immediately stop the feeding and notify provider
B) Reinstill the residual and continue the feeding
C) Elevate HOB to 45° and recheck in 1 hour
D) Switch to post-pyloric feeding without assessment
Answer: A
Rationale: Residual >250 mL indicates delayed gastric emptying and aspiration
risk; stopping the feeding and notifying the provider aligns with enteral feeding
protocols while reassessing tolerance.
11. A nurse notes a stage II pressure injury on the client’s heel. Which intervention is
most appropriate?
A) Massage around the area to increase circulation
B) Apply a hydrocolloid dressing and offload heel
C) Use a heating pad to promote perfusion
D) Keep the heel flat on the mattress
Answer: B
Rationale: Hydrocolloid maintains moist healing and offloading removes
pressure; massage can damage tissue, heat increases metabolic demand, and
leaving the heel down perpetuates injury.
12. A client is to receive a subcutaneous injection of heparin. Which site is preferred
for absorption and comfort?
NEW 100% Correct Questions & Verified Answer
1. A nurse enters a client’s room and finds the pulse oximeter reading 87%. Which
action should the nurse take first?
A) Increase the client’s oxygen flow rate
B) Check the probe placement on the client’s finger
C) Notify the provider immediately
D) Obtain an arterial blood gas sample
Answer: B
Rationale: Verify accuracy first; misplaced or poorly perfused probes give false
lows. Acting on an artifact can lead to unnecessary oxygen therapy (common
CMS trap).
2. The nurse is preparing to insert an indwelling urinary catheter. Which action best
reduces the risk of infection?
A) Use clean technique for the meatus and sterile gloves for insertion
B) Perform hand hygiene and don sterile gloves and maintain a sterile field
C) Wear clean gloves and lubricate the catheter tip with tap water
D) Insert the catheter while the client is in a semi-recumbent position
Answer: B
Rationale: Sterile technique throughout insertion is standard; hand hygiene plus
sterile gloves/equipment prevents pathogen introduction into the urethra.
3. A client is prescribed a newly ordered oral medication. The nurse notes the
medication is not in the electronic health record. Which action should the nurse
take first?
A) Give the medication and document it afterward
B) Hold the medication and verify the order with the prescriber
C) Ask the client if they have taken this drug before
D) Administer the medication and notify pharmacy later
Answer: B
Rationale: “Right order” is one of the six rights; giving an unverified drug violates
safe practice and is a classic CMS error.
4. A client on fall precautions attempts to get out of bed unassisted. Which
intervention is most appropriate?
A) Apply wrist restraints to keep the client in bed
B) Raise the bed to the highest position and lower side rails
, C) Place the bed in lowest position and keep call light within reach
D) Keep the room lights dim to promote rest
Answer: C
Rationale: Bed-low position minimizes injury risk if a fall occurs, and an
accessible call light supports safety; restraints are a last resort and require
orders.
5. The nurse is delegating morning hygiene care to an assistive personnel (AP).
Which instruction is most appropriate?
A) “Report any skin redness or areas of warmth to me.”
B) “Apply lotion to any open areas you notice.”
C) “Give the client a bed bath and don’t worry about documenting.”
D) “Use cold water to help stimulate circulation.”
Answer: A
Rationale: Assessment remains the nurse’s responsibility; instructing the AP to
report abnormalities keeps delegation within scope and supports early detection
of skin breakdown.
6. A postoperative client suddenly reports, “Something popped in my belly.” The
nurse notes eviscerated bowel protruding through the incision. Which action
should the nurse take first?
A) Apply sterile saline-soaked gauze and cover the area
B) Push the bowel back in and apply an abdominal binder
C) Offer oral fluids to prevent dehydration
D) Remove the staples to relieve tension
Answer: A
Rationale: Priority is to prevent desiccation and contamination of exposed bowel
with sterile, moist dressings while preparing for immediate surgical repair; never
reinsert organs at bedside.
7. A client’s morning blood glucose is 45 mg/dL. The client is alert but reports
feeling shaky. Which action should the nurse take first?
A) Give 15 g of oral glucose gel or 4 oz of juice
B) Start an IV and administer 50% dextrose
C) Recheck the glucose in 30 minutes without treating
D) Offer a high-protein snack like cheese
Answer: A
Rationale: Conscious hypoglycemia is treated with 15 g rapid-acting
carbohydrate orally; IV dextrose is reserved for altered mental status or inability
to swallow.
8. The nurse is preparing to apply a wrist restraint to an agitated client. Which
action is required?
, A) Secure the restraint to the side rail
B) Obtain a provider order and check circulation every 15 minutes
C) Tie the restraint with a square knot
D) Pad the foot pedals instead
Answer: B
Rationale: A provider order is mandatory, and circulation/distal neurovascular
checks every 15 min ensure safety; restraints must never be tied to side rails or
use square knots (slip knots are safer).
9. A client returns from surgery with a PCA pump. The nurse notes respirations
8/min and SpO₂ 89%. Which medication should the nurse prepare to administer?
A) Naloxone
B) Ketorolac
C) Ondansetron
D) Diphenhydramine
Answer: A
Rationale: Opioid-induced respiratory depression is reversed with naloxone; the
other drugs do not treat respiratory depression.
10. A client is receiving a continuous enteral feeding. Gastric residual volume is 275
mL. Which action should the nurse take first?
A) Immediately stop the feeding and notify provider
B) Reinstill the residual and continue the feeding
C) Elevate HOB to 45° and recheck in 1 hour
D) Switch to post-pyloric feeding without assessment
Answer: A
Rationale: Residual >250 mL indicates delayed gastric emptying and aspiration
risk; stopping the feeding and notifying the provider aligns with enteral feeding
protocols while reassessing tolerance.
11. A nurse notes a stage II pressure injury on the client’s heel. Which intervention is
most appropriate?
A) Massage around the area to increase circulation
B) Apply a hydrocolloid dressing and offload heel
C) Use a heating pad to promote perfusion
D) Keep the heel flat on the mattress
Answer: B
Rationale: Hydrocolloid maintains moist healing and offloading removes
pressure; massage can damage tissue, heat increases metabolic demand, and
leaving the heel down perpetuates injury.
12. A client is to receive a subcutaneous injection of heparin. Which site is preferred
for absorption and comfort?
