CMS MedSurg
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. - ANSB. 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. - ANSB. 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." - ANSA. "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 - ANSD. 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. - ANSA. 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. - ANSD. 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. - ANSB. 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." - ANSD. "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?" - ANSB. "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 - ANSC. 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. - ANSA. 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." - ANSA. "I will increase my intake of
lean red meat."
A nurse is reinforcing discharge teaching with a client who had an abdominal hysterectomy 2
days ago. Which of the following instructions should the nurse include in the teaching?
A. "Douche with warm water to remove vaginal discharge."
B. "Take a shower rather than a tub bath."
C. "Avoid climbing stairs for 8 weeks."
D. "Expect bright red vaginal bleeding for 1 week following surgery." - ANSB. "Take a shower
rather than a tub bath."
A nurse is reinforcing teaching about meal planning with a client who has hypertension.
Which of the following, statements by the client indicates an understanding of the teaching?
A. "I can have a bologna sandwich."
B. "I can season food with vinegar."
C. "I can have canned soup."
D. "I can season food with ketchup." - ANSB. "I can season food with vinegar."
A nurse is caring for a client who has diabetes mellitus. Which of the following laboratory
findings indicates the client has maintained control of his blood glucose levels for the past 3
months?
A. Fasting blood glucose 100 mg/dL
B. HBA1C 6.5%
C. HbA1C 12.5%
D. Fasting blood glucose 70 mg/dL - ANSB. HBA1C 6.5%
, A nurse is reinforcing teaching with a client who has diabetes mellitus about reducing the
risk for a stroke. Which of the following statements by the client indicates an understanding
of the teaching?
A. "Having a total cholesterol level below 200 mg/dL increases my risk for a stroke."
B. "My provider might prescribe a glucocorticoid regimen to decrease my risk for a stroke."
C. "I can decrease my risk for a stroke by losing excess weight."
D. "My risk for a stroke Increases if my HbA1c level Is 6 percent or less." - ANSC. "I can
decrease my risk for a stroke by losing excess weight."
A nurse is caring for a client who has chronic kidney disease. Which of the following
interventions is appropriate?
A. Offer the client a high-protein diet.
B. Administer NSAIDs for discomfort.
C. Monitor the client for hypokalemia.
D. Obtain the client's daily weight. - ANSC. Monitor the client for hypokalemia.
A nurse is caring for a client who is experiencing muscle spasms and has a new prescription
for an aquathermia pad. Which of the following actions should the nurse take?
A. Fill the pad with sterile water.
B. Apply the pad for 45 min at a time.
C. Cover the pad prior to use.
D. Use safety pins to secure the pad in place. - ANSC. Cover the pad prior to use.
A nurse is reinforcing discharge teaching with a client regarding self-administration of regular
insulin. Which of the following instructions should the nurse include?
A. Store opened insulin vials at room temperature for up to 4 weeks.
B. Warm the insulin vial to dissolve any crystals that develop.
C. Plan to eat a snack 6 hr after insulin administration.
D. Keep unopened insulin vials in the freezer. - ANSA. Store opened insulin vials at room
temperature for up to 4 weeks.
A nurse is preparing to enter the room of a client who has tuberculosis. Which of the
following personal protective equipment should the nurse wear?
A. Venturi mask
B. surgical mask
C. Respirator mask
D. Nonrebreather mask - ANSC. Respirator mask
A nurse is assisting in the plan of care for a client who has thrombocytopenia. Which of the
following actions should the nurse include in the plan?
A. Initiate protective isolation for the client
B. Administer Ibuprofen for mild headache.
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. - ANSB. 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. - ANSB. 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." - ANSA. "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 - ANSD. 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. - ANSA. 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. - ANSD. 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. - ANSB. 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." - ANSD. "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?" - ANSB. "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 - ANSC. 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. - ANSA. 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." - ANSA. "I will increase my intake of
lean red meat."
A nurse is reinforcing discharge teaching with a client who had an abdominal hysterectomy 2
days ago. Which of the following instructions should the nurse include in the teaching?
A. "Douche with warm water to remove vaginal discharge."
B. "Take a shower rather than a tub bath."
C. "Avoid climbing stairs for 8 weeks."
D. "Expect bright red vaginal bleeding for 1 week following surgery." - ANSB. "Take a shower
rather than a tub bath."
A nurse is reinforcing teaching about meal planning with a client who has hypertension.
Which of the following, statements by the client indicates an understanding of the teaching?
A. "I can have a bologna sandwich."
B. "I can season food with vinegar."
C. "I can have canned soup."
D. "I can season food with ketchup." - ANSB. "I can season food with vinegar."
A nurse is caring for a client who has diabetes mellitus. Which of the following laboratory
findings indicates the client has maintained control of his blood glucose levels for the past 3
months?
A. Fasting blood glucose 100 mg/dL
B. HBA1C 6.5%
C. HbA1C 12.5%
D. Fasting blood glucose 70 mg/dL - ANSB. HBA1C 6.5%
, A nurse is reinforcing teaching with a client who has diabetes mellitus about reducing the
risk for a stroke. Which of the following statements by the client indicates an understanding
of the teaching?
A. "Having a total cholesterol level below 200 mg/dL increases my risk for a stroke."
B. "My provider might prescribe a glucocorticoid regimen to decrease my risk for a stroke."
C. "I can decrease my risk for a stroke by losing excess weight."
D. "My risk for a stroke Increases if my HbA1c level Is 6 percent or less." - ANSC. "I can
decrease my risk for a stroke by losing excess weight."
A nurse is caring for a client who has chronic kidney disease. Which of the following
interventions is appropriate?
A. Offer the client a high-protein diet.
B. Administer NSAIDs for discomfort.
C. Monitor the client for hypokalemia.
D. Obtain the client's daily weight. - ANSC. Monitor the client for hypokalemia.
A nurse is caring for a client who is experiencing muscle spasms and has a new prescription
for an aquathermia pad. Which of the following actions should the nurse take?
A. Fill the pad with sterile water.
B. Apply the pad for 45 min at a time.
C. Cover the pad prior to use.
D. Use safety pins to secure the pad in place. - ANSC. Cover the pad prior to use.
A nurse is reinforcing discharge teaching with a client regarding self-administration of regular
insulin. Which of the following instructions should the nurse include?
A. Store opened insulin vials at room temperature for up to 4 weeks.
B. Warm the insulin vial to dissolve any crystals that develop.
C. Plan to eat a snack 6 hr after insulin administration.
D. Keep unopened insulin vials in the freezer. - ANSA. Store opened insulin vials at room
temperature for up to 4 weeks.
A nurse is preparing to enter the room of a client who has tuberculosis. Which of the
following personal protective equipment should the nurse wear?
A. Venturi mask
B. surgical mask
C. Respirator mask
D. Nonrebreather mask - ANSC. Respirator mask
A nurse is assisting in the plan of care for a client who has thrombocytopenia. Which of the
following actions should the nurse include in the plan?
A. Initiate protective isolation for the client
B. Administer Ibuprofen for mild headache.
