PN Adult Medical Surgical CMS Exam
Latest Update 2025 With 100% Complete
Questions and Verified Solutions
Already Graded A+
A nurse is preparing to administer subcutaneous enoxaparin. In which order should the nurse perform
the following steps? (Move the steps into the box on the right, placing them in order of performance.
Use all stamps.)
a) Check the medication administration record to verify the client's allergies.
b) Ensure an air bubble is present in the prefilled enoxaparin syringe.
c) Locate the injection site 5 cm (2 in) to the right or left of the umbilicus.
d) Pinch clean skin at the injection site and dart the needle into the skinfold at a 90 degree angle
e) Slowly inject the medication into the site without aspirating. - CORRECT ANSWER-A. Check
the medication administration record to verify the client's allergies.
B. Ensure an air bubble is present in the prefilled enoxaparin syringe.
,C. Locate the injection site 5 cm (2 in) to the right or left of the umbilicus.
D. Pinch clean skin at the injection site and dart the needle into the skinfold at a 90 degree angle
E. Slowly inject the medication into the site without aspirating.
A nurse is collecting data from a client who is African-American. Which of the following areas should the
nurse check to determine the presence of pallor?
,a) Antecubital space
b) Pinna of the ear
c) Abdomen
d) Conjunctiva - CORRECT ANSWER-d) Conjunctiva
TEST
A nurse is caring for a client who is postoperative following an appendectomy. Which of the following
information should the nurse include when documenting in the electronic medical record?
a) Incision healing well
b) Client status unchanged throughout shift
c) Abdominal wound dry, without redness
d) Client received an adequate amount of fluid - CORRECT ANSWER-C. Abdominal wound dry,
without redness
Rationale:
According to the ANA's Principles for Nursing Documentation, documentation should be accurate,
timely, complete, factual, organized and compliant. It should also reflect the nursing process and the full
extent of a nurse's professional capabilities. Some of the information that should be included when
documenting in the electronic medical record are:
The patient's status, needs, problems, goals, interventions and outcomes
The time and date of each entry
The medication administered, the route, the dosage, and the patient's response.
The precautions or preventive measures used, such as bed rails.
, The patient's refusal of treatment or medication, and the actions taken3
Any phone calls to the physician, including the message and response.
The incision site, its appearance, any drainage, dressing changes, and signs of infection.
TEST
A nurse is caring for a client who is 24 hrs postoperative following abdominal surgery. The client
received an opioid analgesic 1 hr ago and now reports a pain level of 2 on a scale of 0 to 10. Which of
the following actions should the nurse take?
a) Reposition the client.
b) Administer an additional dose of pain medication.
c) Maintain the client on bed rest.
d) Apply a warm, moist compress to the incision area. - CORRECT ANSWER-A. Reposition the
client.
Rationale:
Since the patient had analgesic 1 hr ago and report pain only at 2 out of 10. Reposition the patient can
alleviate that pain.
TEST
A nurse is reinforcing teaching about immunizations with an older adult client. Which of the following
instructions should the nurse include?
a) "You should receive the live, attenuated influenza vaccine every other year."
b) "You should receive the hepatitis A vaccine
every 10 years."
c) "You should receive the human
Latest Update 2025 With 100% Complete
Questions and Verified Solutions
Already Graded A+
A nurse is preparing to administer subcutaneous enoxaparin. In which order should the nurse perform
the following steps? (Move the steps into the box on the right, placing them in order of performance.
Use all stamps.)
a) Check the medication administration record to verify the client's allergies.
b) Ensure an air bubble is present in the prefilled enoxaparin syringe.
c) Locate the injection site 5 cm (2 in) to the right or left of the umbilicus.
d) Pinch clean skin at the injection site and dart the needle into the skinfold at a 90 degree angle
e) Slowly inject the medication into the site without aspirating. - CORRECT ANSWER-A. Check
the medication administration record to verify the client's allergies.
B. Ensure an air bubble is present in the prefilled enoxaparin syringe.
,C. Locate the injection site 5 cm (2 in) to the right or left of the umbilicus.
D. Pinch clean skin at the injection site and dart the needle into the skinfold at a 90 degree angle
E. Slowly inject the medication into the site without aspirating.
A nurse is collecting data from a client who is African-American. Which of the following areas should the
nurse check to determine the presence of pallor?
,a) Antecubital space
b) Pinna of the ear
c) Abdomen
d) Conjunctiva - CORRECT ANSWER-d) Conjunctiva
TEST
A nurse is caring for a client who is postoperative following an appendectomy. Which of the following
information should the nurse include when documenting in the electronic medical record?
a) Incision healing well
b) Client status unchanged throughout shift
c) Abdominal wound dry, without redness
d) Client received an adequate amount of fluid - CORRECT ANSWER-C. Abdominal wound dry,
without redness
Rationale:
According to the ANA's Principles for Nursing Documentation, documentation should be accurate,
timely, complete, factual, organized and compliant. It should also reflect the nursing process and the full
extent of a nurse's professional capabilities. Some of the information that should be included when
documenting in the electronic medical record are:
The patient's status, needs, problems, goals, interventions and outcomes
The time and date of each entry
The medication administered, the route, the dosage, and the patient's response.
The precautions or preventive measures used, such as bed rails.
, The patient's refusal of treatment or medication, and the actions taken3
Any phone calls to the physician, including the message and response.
The incision site, its appearance, any drainage, dressing changes, and signs of infection.
TEST
A nurse is caring for a client who is 24 hrs postoperative following abdominal surgery. The client
received an opioid analgesic 1 hr ago and now reports a pain level of 2 on a scale of 0 to 10. Which of
the following actions should the nurse take?
a) Reposition the client.
b) Administer an additional dose of pain medication.
c) Maintain the client on bed rest.
d) Apply a warm, moist compress to the incision area. - CORRECT ANSWER-A. Reposition the
client.
Rationale:
Since the patient had analgesic 1 hr ago and report pain only at 2 out of 10. Reposition the patient can
alleviate that pain.
TEST
A nurse is reinforcing teaching about immunizations with an older adult client. Which of the following
instructions should the nurse include?
a) "You should receive the live, attenuated influenza vaccine every other year."
b) "You should receive the hepatitis A vaccine
every 10 years."
c) "You should receive the human
