lOMoARcPSD|26582732
ATI ADULT MEDICAL SURGICAL NURSING CONTENT MASTERY
SERIES (CMS) EXAMS STUDY GUIDE ACTUAL EXAM 2025
The nurse is assessing a client's skin for local signs of infection.
Which signs does the nurse assess for? (select all that apply.)
A) Redness
B) Fever
C) Increased erythrocyte sedimentation rate (esr)
D) Pain
E) Swelling
F) Warmth - correct answer a,d,e,f
Localized signs of infection include redness, warmth, pain, swelling, heat, and
pus. Fever and increased esr are systemic signs of infection.
Which client is at highest risk of compromised immunity?
A) Client with extreme anxiety
B) Client who is awaiting surgery
C) Client who has just had surgery
D) Client who just delivered a baby - correct answer c
Intact skin is a defense to prevent infection; however, a client who has recently
had surgery has a portal for organisms to enter the body and cause infection.
A client is admitted with left lower lung pneumonia. Which assessment finding
does the nurse correlate with this condition?
A) Expiratory wheeze on the right side
B) Crackles heard on expiration bilaterally
C) Dullness to percussion on the lower left side
D) Crepitus of the skin around the left lung - correct answer c
The client with pneumonia may have dullness to percussion on the affected side.
The other options are all inconsistent with pneumonia.
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The nurse auscultates the following lung sound in the client with pneumonia.
What is the best intervention?
Audio clip
A) Administer iv fluids.
B) Have the client use an incentive spirometer.
C) Have the client cough and deep breathe.
D) Prepare to administer a bronchodilator. - correct answer b
The sound heard is crackles. Crackles often indicate atelectasis, which can be
reversed by using an incentive spirometer. If no spirometer is available, coughing
and deep breathing is the next best option. This client does not have wheezing,
so bronchodilators are not indicated. Iv fluids would not help atelectasis.
A client with a history of heart failure is being discharged. Which priority
instruction will assist the client in the prevention of complications associated
with heart failure?
A) "eat six small meals daily instead of three larger meals."
B) "when you feel short of breath, take an additional diuretic."
C) "avoid drinking more than 3 quarts of liquids each day."
D) "weigh yourself daily while wearing the same amount of clothing." -
Correct answer d
Clients with heart failure are instructed to weigh themselves daily to detect
worsening heart failure early, and thus avoid complications. Other signs of
worsening heart failure include increasing dyspnea, exercise intolerance, cold
symptoms, and nocturia.
The nurse assesses a client's legs. Which assessment finding indicates arterial
insufficiency?
A) Pain with activity but not while resting
B) Dependent mottling and absence of hair
C) Full veins present in dependent extremity
D) Ankle discoloration and pitting edema - correct answer b dependent mottling
and absence of hair is an indication of arterial insufficiency. Pain may be
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present with activity and at rest. Edema and ankle discoloration would be
indicative of venous insufficiency.
The nurse is teaching a client with pneumonia ways to clear secretions. Which
intervention is the most effective?
A) Administering an antiemetic medication
B) Increasing fluids to 2 l/day if tolerated
C) Administering an antitussive medication
D) Having the client cough and deep breathe hourly - correct
Answer b
Increasing fluids has been proven to decrease the thickness of secretions, thus
allowing them to be expectorated quickly. The other interventions would not be as
effective.
The nurse is assessing a client with left-sided heart failure. What conditions does
the nurse assess for? (select all that apply.)
A) S3/s4 summation gallop
B) Cough worsens at night
C) Dependent edema
D) Pulmonary crackles
E) Confusion, restlessness
F) Pulmonary hypertension - correct answer a,b,d,e
Left-sided failure occurs with a decrease in contractility of the heart or an
increase in afterload. Most of the signs will be noted in the respiratory system.
Right-sided failure occurs with problems from the pulmonary vasculature onward.
Signs will be noted before the right atrium or ventricle.
The nurse assesses the patient and notes all of the following. Select all of the
findings that indicate the systemic manifestations of inflammation.
A) Oral temperature 38.6 f
B) Wbc 20
C) Thick, green nasal discharge
D) Patient reports, "i'm tired all the time. I haven't felt like myself in days"
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E) Patient complaint of pain at 6 on a 0 to 10 scale on palpation of frontal and
maxillary sinuses - correct answer a,b,d
Systemic manifestations of inflammatory response include elevated temperature,
leukocytosis, and malaise and fatigue. Purulent exudates and pain are both
considered local manifestations of inflammation.
A client with chronic obstructive pulmonary disease (copd) reports social
isolation. What does the nurse encourage the client to do?
A) Participate in community activities.
B) Verbalize his or her thoughts and feelings.
C) Ask the client's physician for an antianxiety agent.
D) Join a support group for people with copd. - correct answer b
Many clients with moderate to severe copd become socially isolated because they
are embarrassed by frequent coughing and mucus production. They also can
experience fatigue, which limits their activities. The nurse needs to encourage the
client to verbalize thoughts and feelings so that appropriate interventions can be
selected. Joining a support group would not decrease feelings of social isolation
if the client does not verbalize feelings. Antianxiety agents will not help the client
with social isolation. Encouraging a client to participate in activities without
verbalizing concerns also would not be an effective strategy for decreasing social
isolation.
The nurse is assessing a client with lung disease. Which symptom does the nurse
intervene for first?
A) The client's anterior-posterior chest diameter is 2:2.
B) Clubbing of the finger tips is noted.
C) The client is pale.
D) The client has bilateral dependent leg edema. - correct answer
D
The client with bilateral dependent edema may be developing rightsided heart
failure in response to respiratory disease. This symptom should be investigated
right away and reported to the health care provider. Further assessment is
needed. The client with chronic lung disease may develop increased anterior-
posterior diameter and clubbing as responses to chronic hypoxia. These
Downloaded by NELSON KIIRU ()
ATI ADULT MEDICAL SURGICAL NURSING CONTENT MASTERY
SERIES (CMS) EXAMS STUDY GUIDE ACTUAL EXAM 2025
The nurse is assessing a client's skin for local signs of infection.
Which signs does the nurse assess for? (select all that apply.)
A) Redness
B) Fever
C) Increased erythrocyte sedimentation rate (esr)
D) Pain
E) Swelling
F) Warmth - correct answer a,d,e,f
Localized signs of infection include redness, warmth, pain, swelling, heat, and
pus. Fever and increased esr are systemic signs of infection.
Which client is at highest risk of compromised immunity?
A) Client with extreme anxiety
B) Client who is awaiting surgery
C) Client who has just had surgery
D) Client who just delivered a baby - correct answer c
Intact skin is a defense to prevent infection; however, a client who has recently
had surgery has a portal for organisms to enter the body and cause infection.
A client is admitted with left lower lung pneumonia. Which assessment finding
does the nurse correlate with this condition?
A) Expiratory wheeze on the right side
B) Crackles heard on expiration bilaterally
C) Dullness to percussion on the lower left side
D) Crepitus of the skin around the left lung - correct answer c
The client with pneumonia may have dullness to percussion on the affected side.
The other options are all inconsistent with pneumonia.
Downloaded by NELSON KIIRU ()
, lOMoARcPSD|26582732
The nurse auscultates the following lung sound in the client with pneumonia.
What is the best intervention?
Audio clip
A) Administer iv fluids.
B) Have the client use an incentive spirometer.
C) Have the client cough and deep breathe.
D) Prepare to administer a bronchodilator. - correct answer b
The sound heard is crackles. Crackles often indicate atelectasis, which can be
reversed by using an incentive spirometer. If no spirometer is available, coughing
and deep breathing is the next best option. This client does not have wheezing,
so bronchodilators are not indicated. Iv fluids would not help atelectasis.
A client with a history of heart failure is being discharged. Which priority
instruction will assist the client in the prevention of complications associated
with heart failure?
A) "eat six small meals daily instead of three larger meals."
B) "when you feel short of breath, take an additional diuretic."
C) "avoid drinking more than 3 quarts of liquids each day."
D) "weigh yourself daily while wearing the same amount of clothing." -
Correct answer d
Clients with heart failure are instructed to weigh themselves daily to detect
worsening heart failure early, and thus avoid complications. Other signs of
worsening heart failure include increasing dyspnea, exercise intolerance, cold
symptoms, and nocturia.
The nurse assesses a client's legs. Which assessment finding indicates arterial
insufficiency?
A) Pain with activity but not while resting
B) Dependent mottling and absence of hair
C) Full veins present in dependent extremity
D) Ankle discoloration and pitting edema - correct answer b dependent mottling
and absence of hair is an indication of arterial insufficiency. Pain may be
Downloaded by NELSON KIIRU ()
, lOMoARcPSD|26582732
present with activity and at rest. Edema and ankle discoloration would be
indicative of venous insufficiency.
The nurse is teaching a client with pneumonia ways to clear secretions. Which
intervention is the most effective?
A) Administering an antiemetic medication
B) Increasing fluids to 2 l/day if tolerated
C) Administering an antitussive medication
D) Having the client cough and deep breathe hourly - correct
Answer b
Increasing fluids has been proven to decrease the thickness of secretions, thus
allowing them to be expectorated quickly. The other interventions would not be as
effective.
The nurse is assessing a client with left-sided heart failure. What conditions does
the nurse assess for? (select all that apply.)
A) S3/s4 summation gallop
B) Cough worsens at night
C) Dependent edema
D) Pulmonary crackles
E) Confusion, restlessness
F) Pulmonary hypertension - correct answer a,b,d,e
Left-sided failure occurs with a decrease in contractility of the heart or an
increase in afterload. Most of the signs will be noted in the respiratory system.
Right-sided failure occurs with problems from the pulmonary vasculature onward.
Signs will be noted before the right atrium or ventricle.
The nurse assesses the patient and notes all of the following. Select all of the
findings that indicate the systemic manifestations of inflammation.
A) Oral temperature 38.6 f
B) Wbc 20
C) Thick, green nasal discharge
D) Patient reports, "i'm tired all the time. I haven't felt like myself in days"
Downloaded by NELSON KIIRU ()
, lOMoARcPSD|26582732
E) Patient complaint of pain at 6 on a 0 to 10 scale on palpation of frontal and
maxillary sinuses - correct answer a,b,d
Systemic manifestations of inflammatory response include elevated temperature,
leukocytosis, and malaise and fatigue. Purulent exudates and pain are both
considered local manifestations of inflammation.
A client with chronic obstructive pulmonary disease (copd) reports social
isolation. What does the nurse encourage the client to do?
A) Participate in community activities.
B) Verbalize his or her thoughts and feelings.
C) Ask the client's physician for an antianxiety agent.
D) Join a support group for people with copd. - correct answer b
Many clients with moderate to severe copd become socially isolated because they
are embarrassed by frequent coughing and mucus production. They also can
experience fatigue, which limits their activities. The nurse needs to encourage the
client to verbalize thoughts and feelings so that appropriate interventions can be
selected. Joining a support group would not decrease feelings of social isolation
if the client does not verbalize feelings. Antianxiety agents will not help the client
with social isolation. Encouraging a client to participate in activities without
verbalizing concerns also would not be an effective strategy for decreasing social
isolation.
The nurse is assessing a client with lung disease. Which symptom does the nurse
intervene for first?
A) The client's anterior-posterior chest diameter is 2:2.
B) Clubbing of the finger tips is noted.
C) The client is pale.
D) The client has bilateral dependent leg edema. - correct answer
D
The client with bilateral dependent edema may be developing rightsided heart
failure in response to respiratory disease. This symptom should be investigated
right away and reported to the health care provider. Further assessment is
needed. The client with chronic lung disease may develop increased anterior-
posterior diameter and clubbing as responses to chronic hypoxia. These
Downloaded by NELSON KIIRU ()
