RN Adult Medical Surgical Nursing Content Mastery Series (CMS)
Exams STUDY GUIDE ACTUAL EXAM QUESTIONS AND WELL
ELABORATED ANSWERS (MOST TESTED QUESTIONS WITH VERIFIED
ANSWERS) LATEST UPDATES 2025 |ALREADY GRADED A+ (REVISED
EXAM)
A nurse is providing teaching for a client who has stage 2 HIV disease
and is having difficulty maintaining a normal weight. Which of the
following statements by the client should indicate to the nurse an
understanding of the teaching?
A. "I will choose a diet high in fat to help gain weight."
B. "I will be sure to eat three large meals daily."
C. "I will drink up to 1 liter of liquid each day."
D. "I will add high-protein foods to my diet." - CORRECT ANSWER D.
"I will add high-protein foods to my diet."
A nurse is reviewing the plan of care for a client who has systemic
lupus erythematous (SLE). The client reports fatigue, joint tenderness,
swelling, and difficulty urinating. Which of the following laboratory
findings should the nurse anticipate? (SATA)
A. Positive ANA titer
B. Increased hemoglobin
C. 2+ urine protein
D. Increased serum C3 and C4
E. Elevated BUN - CORRECT ANSWER A. Positive ANA titer
C. 2+ urine protein
E. Elevated BUN
A nurse is teaching a client who has SLE about self-care. Which of the
following statements by the client indicates an understanding of the
teaching?
,A. "I should limit my time to 10 minutes in the tanning bed."
B. "I will apply powder to any skin rash."
C. "I should use a mild hair shampoo."
D. "I will inspect my skin once a month for rashes." - CORRECT
ANSWER
In what time frame will brain injury or death occur due to hypoxia if
the patients airway is not patent? - CORRECT ANSWER 3-5 minutes
What all should a nurse inspect for if a client's ability to maintain an
airway is lost? - CORRECT ANSWER for blood, broken teeth, vomitus,
or other foreign materials in the airway that can cause obstruction
What should the nurse do if a client is unresponsive WITHOUT
suspicion of trauma? - CORRECT ANSWER The airway should be
opened with a head-tilt/chin-lift maneuver
When should a nurse not perform the head-tilt/chin-lift maneuver? -
CORRECT ANSWER If the patient has a potential cervical spine injury
What should the nurse do if the patient is unresponsive WITH
suspicion of trauma? - CORRECT ANSWER The airway should be
opened with a modified jaw thrust maneuver
What type of oxygen is indicated for clients who are spontaneously
breathing? - CORRECT ANSWER nonbreather mask with 100%
oxygen
How does a nurse assess a patient's breathing? - CORRECT ANSWER
auscultation of breath sounds, observation of chest expansion and
respiratory effort, notation of rate and depth of respirations,
identification of chest trauma, assessment of tracheal position,
assessment of jugular vein distention
What should the nurse do if the client is not breathing or is breathing
inadequately? - CORRECT ANSWER manual ventilation should be
performed by a bag valve mask with supplemental oxygen or mouth-to-
mask ventilation until bag valve mask can be obtained
,How does a nurse assess a patient's circulation? - CORRECT ANSWER
assess HR, BP, peripheral pulses, and capillary refill for adequate
perfusion
What should nurses consider when it comes to ineffective circulation?
- CORRECT ANSWER cardiac arrest, myocardial disfunction, and
hemorrhage as precursors to shock
How does a nurse restore effective circulation? - CORRECT ANSWER
CPR, assess for external bleeding, hemorrhage control, obtain IV
access using large-bore IV catheters inserted into the antecubital
fossa of both arms, infuse isotonic IV fluids
What can develop if a patients circulation if compromised? - CORRECT
ANSWER Shock
What are the nursing interventions to alleviate shock? - CORRECT
ANSWER administer oxygen, apply pressure to obvious bleeding,
elevate lower extremities to shunt blood to vital organs, administer IV
fluids and blood products, monitor vs, remain with the client
How does a nurse prevent hypothermia? - CORRECT ANSWER
remove wet clothing from patient, cover the patient with warm
blankets, increase the temperature of the room, use a heat lamp to
provide additional warmth, infuse warm IV fluids
What can hypothermia lead to ? - CORRECT ANSWER eventual coma,
hypoxemia, and acidosis
What is the sudden cessation of cardiac function caused most
commonly by ventricular fibrillation or ventricular asystole? -
CORRECT ANSWER cardiac arrest
What is the fluttering of the ventricles causing loss of consciousness,
pulselessness, and no breathing that requires collaborative care to
defibrillate immediately using ACLS protocol? - CORRECT ANSWER
Ventricular fibrillation
, What is the irritable firing of ectopic ventricular beats at a rate of 140
to 180 beats per min that over time a client will become unconscious
and deteriorate into VF? - CORRECT ANSWER Pulseless ventricular
tachycardia
What is the complete absence of electrical ectopic ventricular
movement of the heart where the client is in complete cardiac arrest
and requires implementation of BLS and ACLS protocol? - CORRECT
ANSWER Ventricular asystole
What is a rhythm that appears to have electrical activity but is not
sufficient to stimulate effective cardiac contractions and requires
implementation of BLS and ACLS protocol? - CORRECT ANSWER
Pulseless electrical activity (PEA)
What is the response of the receptor site Alpha 1? - CORRECT
ANSWER activation of receptors in the arterioles of skin, viscera and
mucous membranes, and veins that lead to vasoconstriction
What is the response of the receptor site Beta 1? - CORRECT ANSWER
heart stimulation leads to increased heart rate, increase myocardial
contractility, and increased rate of conduction through the AV node,
and activation of receptors in the kidney leading to the release of
renin
What is the response of the receptor site Beta 2? - CORRECT ANSWER
Bronchodilation, relaxation of uterine smooth muscle, breakdown of
glycogen into glucose, muscle contraction
What is the response of the receptor site dopamine? - CORRECT
ANSWER activation of receptors in the kidney cause the renal blood
vessels to dilate
What are the 5 H's when it comes to common causes of PEA? -
CORRECT ANSWER Hypovolemia, hypoxia, hydrogen ion
accumulation, resulting in acidosis, hyperkalemia or hypokalemia, and
hypothermia
Exams STUDY GUIDE ACTUAL EXAM QUESTIONS AND WELL
ELABORATED ANSWERS (MOST TESTED QUESTIONS WITH VERIFIED
ANSWERS) LATEST UPDATES 2025 |ALREADY GRADED A+ (REVISED
EXAM)
A nurse is providing teaching for a client who has stage 2 HIV disease
and is having difficulty maintaining a normal weight. Which of the
following statements by the client should indicate to the nurse an
understanding of the teaching?
A. "I will choose a diet high in fat to help gain weight."
B. "I will be sure to eat three large meals daily."
C. "I will drink up to 1 liter of liquid each day."
D. "I will add high-protein foods to my diet." - CORRECT ANSWER D.
"I will add high-protein foods to my diet."
A nurse is reviewing the plan of care for a client who has systemic
lupus erythematous (SLE). The client reports fatigue, joint tenderness,
swelling, and difficulty urinating. Which of the following laboratory
findings should the nurse anticipate? (SATA)
A. Positive ANA titer
B. Increased hemoglobin
C. 2+ urine protein
D. Increased serum C3 and C4
E. Elevated BUN - CORRECT ANSWER A. Positive ANA titer
C. 2+ urine protein
E. Elevated BUN
A nurse is teaching a client who has SLE about self-care. Which of the
following statements by the client indicates an understanding of the
teaching?
,A. "I should limit my time to 10 minutes in the tanning bed."
B. "I will apply powder to any skin rash."
C. "I should use a mild hair shampoo."
D. "I will inspect my skin once a month for rashes." - CORRECT
ANSWER
In what time frame will brain injury or death occur due to hypoxia if
the patients airway is not patent? - CORRECT ANSWER 3-5 minutes
What all should a nurse inspect for if a client's ability to maintain an
airway is lost? - CORRECT ANSWER for blood, broken teeth, vomitus,
or other foreign materials in the airway that can cause obstruction
What should the nurse do if a client is unresponsive WITHOUT
suspicion of trauma? - CORRECT ANSWER The airway should be
opened with a head-tilt/chin-lift maneuver
When should a nurse not perform the head-tilt/chin-lift maneuver? -
CORRECT ANSWER If the patient has a potential cervical spine injury
What should the nurse do if the patient is unresponsive WITH
suspicion of trauma? - CORRECT ANSWER The airway should be
opened with a modified jaw thrust maneuver
What type of oxygen is indicated for clients who are spontaneously
breathing? - CORRECT ANSWER nonbreather mask with 100%
oxygen
How does a nurse assess a patient's breathing? - CORRECT ANSWER
auscultation of breath sounds, observation of chest expansion and
respiratory effort, notation of rate and depth of respirations,
identification of chest trauma, assessment of tracheal position,
assessment of jugular vein distention
What should the nurse do if the client is not breathing or is breathing
inadequately? - CORRECT ANSWER manual ventilation should be
performed by a bag valve mask with supplemental oxygen or mouth-to-
mask ventilation until bag valve mask can be obtained
,How does a nurse assess a patient's circulation? - CORRECT ANSWER
assess HR, BP, peripheral pulses, and capillary refill for adequate
perfusion
What should nurses consider when it comes to ineffective circulation?
- CORRECT ANSWER cardiac arrest, myocardial disfunction, and
hemorrhage as precursors to shock
How does a nurse restore effective circulation? - CORRECT ANSWER
CPR, assess for external bleeding, hemorrhage control, obtain IV
access using large-bore IV catheters inserted into the antecubital
fossa of both arms, infuse isotonic IV fluids
What can develop if a patients circulation if compromised? - CORRECT
ANSWER Shock
What are the nursing interventions to alleviate shock? - CORRECT
ANSWER administer oxygen, apply pressure to obvious bleeding,
elevate lower extremities to shunt blood to vital organs, administer IV
fluids and blood products, monitor vs, remain with the client
How does a nurse prevent hypothermia? - CORRECT ANSWER
remove wet clothing from patient, cover the patient with warm
blankets, increase the temperature of the room, use a heat lamp to
provide additional warmth, infuse warm IV fluids
What can hypothermia lead to ? - CORRECT ANSWER eventual coma,
hypoxemia, and acidosis
What is the sudden cessation of cardiac function caused most
commonly by ventricular fibrillation or ventricular asystole? -
CORRECT ANSWER cardiac arrest
What is the fluttering of the ventricles causing loss of consciousness,
pulselessness, and no breathing that requires collaborative care to
defibrillate immediately using ACLS protocol? - CORRECT ANSWER
Ventricular fibrillation
, What is the irritable firing of ectopic ventricular beats at a rate of 140
to 180 beats per min that over time a client will become unconscious
and deteriorate into VF? - CORRECT ANSWER Pulseless ventricular
tachycardia
What is the complete absence of electrical ectopic ventricular
movement of the heart where the client is in complete cardiac arrest
and requires implementation of BLS and ACLS protocol? - CORRECT
ANSWER Ventricular asystole
What is a rhythm that appears to have electrical activity but is not
sufficient to stimulate effective cardiac contractions and requires
implementation of BLS and ACLS protocol? - CORRECT ANSWER
Pulseless electrical activity (PEA)
What is the response of the receptor site Alpha 1? - CORRECT
ANSWER activation of receptors in the arterioles of skin, viscera and
mucous membranes, and veins that lead to vasoconstriction
What is the response of the receptor site Beta 1? - CORRECT ANSWER
heart stimulation leads to increased heart rate, increase myocardial
contractility, and increased rate of conduction through the AV node,
and activation of receptors in the kidney leading to the release of
renin
What is the response of the receptor site Beta 2? - CORRECT ANSWER
Bronchodilation, relaxation of uterine smooth muscle, breakdown of
glycogen into glucose, muscle contraction
What is the response of the receptor site dopamine? - CORRECT
ANSWER activation of receptors in the kidney cause the renal blood
vessels to dilate
What are the 5 H's when it comes to common causes of PEA? -
CORRECT ANSWER Hypovolemia, hypoxia, hydrogen ion
accumulation, resulting in acidosis, hyperkalemia or hypokalemia, and
hypothermia
