LVN FUNDAMENTALS CMS EXAM
QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES ||
100% GUARANTEED PASS!!
<LATEST VERSION>
Question 1
A nurse is preparing to change a sterile dressing on a client’s surgical incision.
Which action contaminates the sterile field?
A. Holding sterile forceps 2.5 cm (1 inch) above the field
B. Turning the head away from the field
C. Reaching across the sterile field
D. Opening the sterile package away from the body
Correct Answer: C
Rationale: Reaching across a sterile field contaminates it because the nurse’s
clothing and hands are not sterile beyond the sterile gloves.
Question 2
A nurse is caring for a client with a Stage 2 pressure injury. Which finding is
expected?
A. Exposed muscle tissue
B. Partial-thickness skin loss
C. Full-thickness skin loss
D. Necrotic tissue covering the wound
,Correct Answer: B
Rationale: Stage 2 pressure injuries involve partial-thickness loss of skin,
presenting as a shallow open ulcer or blister.
Question 3
A nurse is delegating tasks to unlicensed assistive personnel (UAP). Which task is
appropriate to delegate?
A. Teaching a client to use an incentive spirometer
B. Assessing pain level after medication administration
C. Obtaining a routine blood pressure
D. Evaluating a client’s response to treatment
Correct Answer: C
Rationale: Obtaining routine vital signs is a predictable, non-invasive task
appropriate for UAP under proper supervision.
Question 4
A nurse notes cloudy drainage in a client’s wound. What is the nurse’s priority
action?
A. Document the finding
B. Notify the provider
C. Reinforce the dressing
D. Apply additional sterile gauze
Correct Answer: B
Rationale: Cloudy drainage may indicate infection and must be promptly reported
to the provider.
,Question 5
When performing hand hygiene, which action is most effective in preventing
infection?
A. Wearing gloves
B. Using antibacterial soap
C. Washing hands before and after client contact
D. Cleaning under fingernails once daily
Correct Answer: C
Rationale: Hand hygiene before and after each client contact is the most effective
method to prevent transmission of microorganisms.
Question 6
A nurse is assisting with tracheostomy care. Which solution is appropriate for
cleaning the inner cannula?
A. Normal saline only
B. Hydrogen peroxide followed by saline
C. Sterile water only
D. Alcohol solution
Correct Answer: B
Rationale: Hydrogen peroxide helps loosen secretions and is followed by saline to
prevent tissue irritation.
Question 7
A nurse is measuring an obese client’s blood pressure. Which cuff size is
appropriate?
A. Pediatric cuff
B. Standard adult cuff
C. Large adult cuff
D. Thigh cuff
, Correct Answer: C
Rationale: A cuff that is too small yields falsely elevated readings; a large adult
cuff ensures accuracy.
Question 8
Which action by a nurse demonstrates proper client advocacy?
A. Encouraging the client to follow provider orders without question
B. Reporting unsafe staffing levels
C. Sharing client information with family
D. Withholding information to avoid anxiety
Correct Answer: B
Rationale: Client advocacy includes protecting safety and reporting unsafe
conditions.
Question 9
A nurse is assisting a postoperative client with coughing and deep breathing. What
is the purpose of this intervention?
A. Improve circulation
B. Reduce pain
C. Prevent atelectasis
D. Promote wound healing
Correct Answer: C
Rationale: Coughing and deep breathing help expand alveoli and prevent
atelectasis after surgery.
QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES ||
100% GUARANTEED PASS!!
<LATEST VERSION>
Question 1
A nurse is preparing to change a sterile dressing on a client’s surgical incision.
Which action contaminates the sterile field?
A. Holding sterile forceps 2.5 cm (1 inch) above the field
B. Turning the head away from the field
C. Reaching across the sterile field
D. Opening the sterile package away from the body
Correct Answer: C
Rationale: Reaching across a sterile field contaminates it because the nurse’s
clothing and hands are not sterile beyond the sterile gloves.
Question 2
A nurse is caring for a client with a Stage 2 pressure injury. Which finding is
expected?
A. Exposed muscle tissue
B. Partial-thickness skin loss
C. Full-thickness skin loss
D. Necrotic tissue covering the wound
,Correct Answer: B
Rationale: Stage 2 pressure injuries involve partial-thickness loss of skin,
presenting as a shallow open ulcer or blister.
Question 3
A nurse is delegating tasks to unlicensed assistive personnel (UAP). Which task is
appropriate to delegate?
A. Teaching a client to use an incentive spirometer
B. Assessing pain level after medication administration
C. Obtaining a routine blood pressure
D. Evaluating a client’s response to treatment
Correct Answer: C
Rationale: Obtaining routine vital signs is a predictable, non-invasive task
appropriate for UAP under proper supervision.
Question 4
A nurse notes cloudy drainage in a client’s wound. What is the nurse’s priority
action?
A. Document the finding
B. Notify the provider
C. Reinforce the dressing
D. Apply additional sterile gauze
Correct Answer: B
Rationale: Cloudy drainage may indicate infection and must be promptly reported
to the provider.
,Question 5
When performing hand hygiene, which action is most effective in preventing
infection?
A. Wearing gloves
B. Using antibacterial soap
C. Washing hands before and after client contact
D. Cleaning under fingernails once daily
Correct Answer: C
Rationale: Hand hygiene before and after each client contact is the most effective
method to prevent transmission of microorganisms.
Question 6
A nurse is assisting with tracheostomy care. Which solution is appropriate for
cleaning the inner cannula?
A. Normal saline only
B. Hydrogen peroxide followed by saline
C. Sterile water only
D. Alcohol solution
Correct Answer: B
Rationale: Hydrogen peroxide helps loosen secretions and is followed by saline to
prevent tissue irritation.
Question 7
A nurse is measuring an obese client’s blood pressure. Which cuff size is
appropriate?
A. Pediatric cuff
B. Standard adult cuff
C. Large adult cuff
D. Thigh cuff
, Correct Answer: C
Rationale: A cuff that is too small yields falsely elevated readings; a large adult
cuff ensures accuracy.
Question 8
Which action by a nurse demonstrates proper client advocacy?
A. Encouraging the client to follow provider orders without question
B. Reporting unsafe staffing levels
C. Sharing client information with family
D. Withholding information to avoid anxiety
Correct Answer: B
Rationale: Client advocacy includes protecting safety and reporting unsafe
conditions.
Question 9
A nurse is assisting a postoperative client with coughing and deep breathing. What
is the purpose of this intervention?
A. Improve circulation
B. Reduce pain
C. Prevent atelectasis
D. Promote wound healing
Correct Answer: C
Rationale: Coughing and deep breathing help expand alveoli and prevent
atelectasis after surgery.
