PN ADULT MEDICAL SURGICAL CMS EXAM 250
QUESTIONS AND answers WITH RATIONALES
TEST
A nurse is caring for a client who is taking lithium and reports persistent nausea and vomiting for 2 days
Which of the following laboratory values should the nurse report to the provider?
a) Potassium 4.0 mEq/L
b) Lithium 0.9 mEq/L
c) BUN 12 mg/dL
d) Sodium 132 mEq/L - ANS >>D. Sodium 132 mEq/L
Rationale:
The nurse should identify that a sodium level of 132 mEq/L is not within the expected reference range o
136 to 145 mEq/L. This finding indicates hyponatremia, which can lead to lithium accumulation and place
the client at risk for lithium toxicity. The nurse should report this finding to the provider.
A nurse is caring for a client who has cancer and has a WBC count of 4,000/mm3. Which of the followin
actions should the nurse take?
a) Cleanse the client's toothbrush with hydrogen peroxide.
b) Instruct the client to use a disposable razor to shave.
c) Decrease the client's protein intake.
d) Encourage the client to eat unpasteurized dairy products. - ANS >>A. Cleanse the client's toothbrus
with hydrogen peroxide.
Rationale:
A WBC count of 4,000/mm3 is considered low and is known as leukopenia. A low WBC count can b
caused by cancer or cancer treatment. The nurse should instruct the client to cleanse their toothbrus
with hydrogen peroxide. People with leukemia or leukopenia should avoid using disposable razors, whic
,can cause cuts and bleeding that can lead to infections. Instead, they recommend using an electric razo
to reduce the risk of injury. Encouraging the client to eat unpasteurized dairy products is no
recommended as they can contain harmful bacteria that can cause infections. Decreasing the client
protein intake is not recommended as protein is important for wound healing and immune function
TEST
A nurse enters a client's room and sees smoke coming from the bathroom. Which of the following action
should the nurse take first?
a) Activate the fire alarm system.
b) Use a fire extinguisher at the source of the
smoke.
c) Assist the client to a nearby common area.
d) Close the doors to the room and to the
bathroom. - ANS >>C. Assist the client to a nearby common area.
Rationale:
use
Rescue
Alarm
Contain
Extinguish
TEST
A nurse is contributing to the plan of care for a client who reports difficulty eating due to chronic arthritis
Which of the following interventions should the nurse include in the plan?
a) Apply foam handles to the client's eating utensils.
b) Obtain a referral for physical therapy.
c) Have an assistive personnel feed the client.
d) Ask the provider for a prescription for a pureed diet. - ANS >>A. Apply foam handles to the client
eating utensils.
Rationale:
To help a client with chronic arthritis who experiences difficulty eating, applying foam handles to th
eating utensils can provide a larger, more comfortable grip and reduce strain on the joints. Asking for
puree diet may not be necessary unless swallowing difficulties are present. Having an assistive personne
,feed the client may not promote independence. While obtaining a referral for physical therapy may b
beneficial for overall mobility, it does not directly address the client's difficulty with eating.
A nurse is providing directions to an assistive personnel about moving a client up in bed.
a. "Place a pillow under the client's head prior to repositioning."
b. "Keep your feet close together while moving the client"
c "Face in the direction of the client's movement"
d. "Move the client's arms to his sides prior to repositioning." - ANS >>C. "Face in the direction of th
client's movement."
Rational:
When moving a client up in bed, it is important for the nurse to face in the direction of the client
movement to maintain proper body mechanics and ensure safe transfer.
1)Adjust the head of the bed to a flat position.
2)Remove all pillows from under the client.
3)Position the UAP on the side opposite the nurse.
4)Place a friction-reducing sheet under the client.
5)Ask the client to bend the legs and place the chin on the chest.
6)Grasp the sheet and move the client on the count of three.
A nurse is obtaining a medication history from a client who is to start taking nitroglycerin for ches
discomfort with activity. Which of the following medications should the nurse instruct the client to avoi
taking within 24 hrs of using nitroglycerin?
a) Atorvastatin
b) Metformin
c) Sildenafil
d) Omeprazole - ANS >>C. Sildenafil
Rationale:
Sildenafil treats PAH (pulmonary arterial hypertension) by relaxing the blood vessels in the lungs to allo
blood to flow easily.
, Same as, nitroglycerin is a vaso-dilator which is primarily to treat anginal chest pain and thereby it reduce
blood pressure.
Remaining drugs like omeprazole and atorvastatin can be given for patients with in 24hrs of nitroglyceri
administration.
A nurse is caring for a client who has a new prescription for nitroglycerin. The nurse should monitor fo
which of the following adverse effects of the medication?
Nocturia
Increased saliva production
Flushing
Fever - ANS >>Flushing
Rationale:
nitroglycerin is a vaso-dilator. When vaso-dilators too well, fluid start sipping out and causing flushing
A nurse is preparing to obtain a postprandial blood glucose level from a client who has diabetes mellitus
Which of the following actions should the nurse take?
a) Apply the first drop of blood to the test strip.
b) Clean the client's finger with hexachlorophene.
c) Prick the central tip of the client's finger.
d) Hold the client's finger in a dependent position. - ANS >>D. Hold the client's finger in a dependent
position.
Rationale:
The nurse should clean the client's finger with an alcohol swab and prick the side of the finger, not th
central tip, to obtain a postprandial blood glucose level.
The nurse should not apply the first drop of blood to the test strip since the alcohol could cause fals
reading.
Hexachlorophene is not recommended for cleaning the client's finger as it can cause tissue damage.
TEST
A nurse is reinforcing teaching with a client about breast self-examinations. Which of the followin
statements by the client indicates an understanding of the teaching?
QUESTIONS AND answers WITH RATIONALES
TEST
A nurse is caring for a client who is taking lithium and reports persistent nausea and vomiting for 2 days
Which of the following laboratory values should the nurse report to the provider?
a) Potassium 4.0 mEq/L
b) Lithium 0.9 mEq/L
c) BUN 12 mg/dL
d) Sodium 132 mEq/L - ANS >>D. Sodium 132 mEq/L
Rationale:
The nurse should identify that a sodium level of 132 mEq/L is not within the expected reference range o
136 to 145 mEq/L. This finding indicates hyponatremia, which can lead to lithium accumulation and place
the client at risk for lithium toxicity. The nurse should report this finding to the provider.
A nurse is caring for a client who has cancer and has a WBC count of 4,000/mm3. Which of the followin
actions should the nurse take?
a) Cleanse the client's toothbrush with hydrogen peroxide.
b) Instruct the client to use a disposable razor to shave.
c) Decrease the client's protein intake.
d) Encourage the client to eat unpasteurized dairy products. - ANS >>A. Cleanse the client's toothbrus
with hydrogen peroxide.
Rationale:
A WBC count of 4,000/mm3 is considered low and is known as leukopenia. A low WBC count can b
caused by cancer or cancer treatment. The nurse should instruct the client to cleanse their toothbrus
with hydrogen peroxide. People with leukemia or leukopenia should avoid using disposable razors, whic
,can cause cuts and bleeding that can lead to infections. Instead, they recommend using an electric razo
to reduce the risk of injury. Encouraging the client to eat unpasteurized dairy products is no
recommended as they can contain harmful bacteria that can cause infections. Decreasing the client
protein intake is not recommended as protein is important for wound healing and immune function
TEST
A nurse enters a client's room and sees smoke coming from the bathroom. Which of the following action
should the nurse take first?
a) Activate the fire alarm system.
b) Use a fire extinguisher at the source of the
smoke.
c) Assist the client to a nearby common area.
d) Close the doors to the room and to the
bathroom. - ANS >>C. Assist the client to a nearby common area.
Rationale:
use
Rescue
Alarm
Contain
Extinguish
TEST
A nurse is contributing to the plan of care for a client who reports difficulty eating due to chronic arthritis
Which of the following interventions should the nurse include in the plan?
a) Apply foam handles to the client's eating utensils.
b) Obtain a referral for physical therapy.
c) Have an assistive personnel feed the client.
d) Ask the provider for a prescription for a pureed diet. - ANS >>A. Apply foam handles to the client
eating utensils.
Rationale:
To help a client with chronic arthritis who experiences difficulty eating, applying foam handles to th
eating utensils can provide a larger, more comfortable grip and reduce strain on the joints. Asking for
puree diet may not be necessary unless swallowing difficulties are present. Having an assistive personne
,feed the client may not promote independence. While obtaining a referral for physical therapy may b
beneficial for overall mobility, it does not directly address the client's difficulty with eating.
A nurse is providing directions to an assistive personnel about moving a client up in bed.
a. "Place a pillow under the client's head prior to repositioning."
b. "Keep your feet close together while moving the client"
c "Face in the direction of the client's movement"
d. "Move the client's arms to his sides prior to repositioning." - ANS >>C. "Face in the direction of th
client's movement."
Rational:
When moving a client up in bed, it is important for the nurse to face in the direction of the client
movement to maintain proper body mechanics and ensure safe transfer.
1)Adjust the head of the bed to a flat position.
2)Remove all pillows from under the client.
3)Position the UAP on the side opposite the nurse.
4)Place a friction-reducing sheet under the client.
5)Ask the client to bend the legs and place the chin on the chest.
6)Grasp the sheet and move the client on the count of three.
A nurse is obtaining a medication history from a client who is to start taking nitroglycerin for ches
discomfort with activity. Which of the following medications should the nurse instruct the client to avoi
taking within 24 hrs of using nitroglycerin?
a) Atorvastatin
b) Metformin
c) Sildenafil
d) Omeprazole - ANS >>C. Sildenafil
Rationale:
Sildenafil treats PAH (pulmonary arterial hypertension) by relaxing the blood vessels in the lungs to allo
blood to flow easily.
, Same as, nitroglycerin is a vaso-dilator which is primarily to treat anginal chest pain and thereby it reduce
blood pressure.
Remaining drugs like omeprazole and atorvastatin can be given for patients with in 24hrs of nitroglyceri
administration.
A nurse is caring for a client who has a new prescription for nitroglycerin. The nurse should monitor fo
which of the following adverse effects of the medication?
Nocturia
Increased saliva production
Flushing
Fever - ANS >>Flushing
Rationale:
nitroglycerin is a vaso-dilator. When vaso-dilators too well, fluid start sipping out and causing flushing
A nurse is preparing to obtain a postprandial blood glucose level from a client who has diabetes mellitus
Which of the following actions should the nurse take?
a) Apply the first drop of blood to the test strip.
b) Clean the client's finger with hexachlorophene.
c) Prick the central tip of the client's finger.
d) Hold the client's finger in a dependent position. - ANS >>D. Hold the client's finger in a dependent
position.
Rationale:
The nurse should clean the client's finger with an alcohol swab and prick the side of the finger, not th
central tip, to obtain a postprandial blood glucose level.
The nurse should not apply the first drop of blood to the test strip since the alcohol could cause fals
reading.
Hexachlorophene is not recommended for cleaning the client's finger as it can cause tissue damage.
TEST
A nurse is reinforcing teaching with a client about breast self-examinations. Which of the followin
statements by the client indicates an understanding of the teaching?
