PN ADULT MEDICAL SURGICAL CMS EXAM 300 ACTUAL QUESTIONS AND CORRECT ANSWER WITH RATIONALE LATEST UPDATE ALREADY GRADED A+

PN ADULT MEDICAL SURGICAL CMS EXAM 300
ACTUAL QUESTIONS AND CORRECT ANSWER WITH
RATIONALE LATEST UPDATE ALREADY GRADED A+




1. A nurse is caring for a client who is 1 day postoperative following abdominal
surgery. The client reports sudden shortness of breath and chest pain. What is the
priority nursing action?
A) Administer oxygen at 2 L/min via nasal cannula
B) Assess the client's oxygen saturation
C) Notify the healthcare provider
D) Elevate the head of the bed to 90 degrees
Correct Answer: B) Assess the client's oxygen saturation
Rationale: The client's symptoms are concerning for a pulmonary embolism. The
priority action is to assess the client's oxygen saturation to determine the severity
of respiratory compromise. Following assessment, the nurse would elevate the
head of the bed, administer oxygen, and notify the provider .

2. A client has been prescribed morphine sulfate for severe postoperative pain. The
nurse should assess for which potential adverse effect?
A) Tachypnea
B) Hypotension
C) Diarrhea
D) Tachycardia
Correct Answer: B) Hypotension
Rationale: Morphine sulfate is an opioid analgesic that can cause hypotension due
to vasodilation, as well as respiratory depression, constipation, and sedation. The
nurse should monitor vital signs closely, especially blood pressure and respiratory
rate .

3. The nurse is performing an admission assessment on a client with pneumonia.
Which finding should the nurse report to the healthcare provider immediately?
A) Temperature of 100.4°F
B) Respiratory rate of 22 breaths/min
C) Oxygen saturation of 88% on room air
D) Productive cough with green sputum

,Correct Answer: C) Oxygen saturation of 88% on room air
Rationale: An oxygen saturation of 88% indicates significant hypoxemia and
requires immediate intervention. Normal oxygen saturation should be 95% or
higher. The nurse should apply oxygen and notify the healthcare provider .

4. The nurse is providing education to a client about pain management. Which
statement indicates the client understands the teaching?
A) "I should wait until my pain is severe before taking medication."
B) "I should take my pain medication on a scheduled basis."
C) "I should only take pain medication if I cannot sleep."
D) "I should avoid pain medication to prevent addiction."
Correct Answer: B) "I should take my pain medication on a scheduled basis."
Rationale: Taking pain medication on a scheduled basis helps maintain a consistent
level of pain relief and prevents pain from becoming severe. This is a more
effective approach than PRN (as needed) dosing for acute pain management .

5. The nurse is caring for a client who is NPO and has an IV infusion of 0.9%
normal saline running at 100 mL/hr. The client develops crackles in the lung bases
and shortness of breath. Which action should the nurse take first?
A) Slow the IV infusion rate
B) Administer furosemide as prescribed
C) Place the client in high-Fowler's position
D) Notify the healthcare provider
Correct Answer: C) Place the client in high-Fowler's position
Rationale: The client is showing signs of fluid volume excess (crackles, shortness
of breath). The priority is to place the client in high-Fowler's position to facilitate
breathing and reduce pulmonary congestion. Then the nurse should slow the
infusion, notify the provider, and administer diuretics as prescribed .

6. The nurse is monitoring a client who is receiving a blood transfusion. Which
finding indicates a transfusion reaction?
A) Flushing and headache
B) Hypotension and tachycardia
C) Urticaria and wheezing
D) Fever and chills
Correct Answer: D) Fever and chills
Rationale: Fever and chills are classic signs of a febrile non-hemolytic transfusion
reaction. Other signs include flushing, headache, tachycardia, and hypotension.
The transfusion should be stopped immediately, and the provider notified .

,7. The nurse is preparing to administer a blood transfusion to a client. Which
action is essential before starting the transfusion?
A) Obtain a signed informed consent
B) Verify the client's identity using two identifiers
C) Check the blood product with another licensed nurse
D) All of the above
Correct Answer: D) All of the above
Rationale: Before initiating a blood transfusion, the nurse must obtain informed
consent, verify the client's identity using two identifiers, and check the blood
product with another licensed nurse. These steps ensure client safety and prevent
transfusion errors .

8. The nurse is assessing a client with a pressure injury. Which finding indicates
wound healing?
A) Eschar formation
B) Purulent drainage
C) Granulation tissue
D) Erythema at the wound edges
Correct Answer: C) Granulation tissue
Rationale: Granulation tissue is a sign of wound healing, appearing as red, moist
tissue that fills the wound bed. Eschar is necrotic tissue that must be removed.
Purulent drainage indicates infection. Erythema may indicate infection or
inflammation .

9. The nurse is caring for a client with diabetes mellitus who has a wound
infection. Which laboratory finding is most indicative of infection?
A) Elevated white blood cell count
B) Decreased hemoglobin
C) Elevated blood glucose
D) Elevated serum creatinine
Correct Answer: A) Elevated white blood cell count
Rationale: An elevated white blood cell count is a classic sign of infection.
Hyperglycemia (elevated blood glucose) is common in diabetic clients with
infection but is not specific to infection. Decreased hemoglobin and elevated
creatinine are not specific indicators of infection .

10. The nurse is providing education to a client with a new colostomy. Which
statement indicates the client understands the teaching?
A) "I will empty the bag when it is completely full."
B) "I will change the bag daily."

, C) "I will clean the stoma with soap and water."
D) "I will cut the wafer to fit snugly around the stoma."
Correct Answer: D) "I will cut the wafer to fit snugly around the stoma."
Rationale: The wafer should be cut to fit snugly around the stoma to prevent skin
breakdown. The bag should be emptied when it is one-third to one-half full, not
when completely full. The bag should be changed every 3 to 7 days. The stoma
should be cleaned with warm water only .

11. The nurse is caring for a client with a new colostomy. Which assessment
finding indicates proper stoma function?
A) The stoma is pale and bluish
B) The stoma is red and moist
C) The stoma is dry and crusted
D) The stoma is swollen and painful
Correct Answer: B) The stoma is red and moist
Rationale: A healthy stoma should be red and moist, similar to the inside of the
mouth. A pale or bluish stoma indicates poor circulation. A dry, crusted stoma may
indicate dehydration or poor stoma care. Swelling and pain may indicate
obstruction or infection .

12. The nurse is preparing a client for surgery. Which assessment finding should be
reported to the healthcare provider before surgery?
A) Blood pressure 140/90 mmHg
B) Serum potassium 3.2 mEq/L
C) Heart rate 88 beats/min
D) Respiratory rate 16 breaths/min
Correct Answer: B) Serum potassium 3.2 mEq/L
Rationale: A serum potassium of 3.2 mEq/L indicates hypokalemia, which can
increase the risk of cardiac dysrhythmias during surgery. The healthcare provider
should be notified before surgery, and potassium supplementation may be needed .

13. The nurse is providing education to a client about deep breathing exercises
following surgery. The purpose of these exercises is to:
A) Prevent constipation
B) Prevent atelectasis and pneumonia
C) Promote wound healing
D) Reduce pain
Correct Answer: B) Prevent atelectasis and pneumonia