CMS Fundamentals Final Exam Questions and Answers with
Complete Solutions | latest Update 2025
Question 1
A nurse is assessing the heart sounds of a client who has developed chest pain that becomes
worse with inspiration. The nurse auscultates a high-pitched scratching sound during both systole
and diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of
the following heart sounds should the nurse document?
A) Audible Click
B) Murmur
C) Third heart sound (S3)
D) Pericardial friction rub
Correct Answer: D) Pericardial friction rub
Rationale: A pericardial friction rub is a classic sign of pericarditis, an inflammation of the
sac surrounding the heart. It is described as a high-pitched, scratching, or grating sound
that is typically heard during both systole and diastole. The pain worsening with
inspiration is also a characteristic symptom of pericarditis.
Question 2
A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following
actions should the nurse take?
A) Auscultate for the blood pressure at the dorsalis pedis artery.
B) Measure the blood pressure with the client sitting on the side of the bed.
C) Place the cuff 7.6 cm (3 in) above the popliteal artery.
D) Place the bladder of the cuff over the posterior aspect of the thigh.
Correct Answer: D) Place the bladder of the cuff over the posterior aspect of the thigh.
Rationale: When measuring blood pressure in the thigh, the popliteal artery is the site for
auscultation. The bladder of the cuff must be positioned directly over this artery, which is
located on the posterior aspect of the thigh, to ensure an accurate reading. The client
should be in a prone or supine position for this measurement.
Question 3
A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly
licensed nurses. Which of the following actions should the charge nurse teach as the first
response in CPR?
A) Call for assistance.
B) Begin chest compressions.
C) Confirm unresponsiveness.
D) Give rescue breaths.
Correct Answer: C) Confirm unresponsiveness.
Rationale: According to the American Heart Association (AHA) guidelines for Basic Life
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Support (BLS), the first step is to assess the scene for safety and then to check for the
victim's responsiveness. You must determine if the person is unconscious and needs help
before initiating any other part of the CPR sequence.
Question 4
A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported for
the procedure, which of the following actions should the nurse take first?
A) Explain the x-ray procedure to the client.
B) Help the client into a wheelchair before the transporter arrives.
C) Ask if the client has any questions.
D) Identify the client using two identifiers.
Correct Answer: D) Identify the client using two identifiers.
Rationale: Patient safety is the top priority. The first and most critical step before any
procedure or transport is to verify the client's identity using at least two identifiers (e.g.,
name and date of birth) and comparing them to the client's wristband and the order. This
ensures that the correct client receives the correct procedure.
Question 5
A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the
following actions should the nurse take?
A) Encourage the child to cough frequently to clear congestion from anesthesia.
B) Place a heating pad on the child's neck for comfort.
C) Administer analgesics to the child on a routine schedule throughout the day and night.
D) Provide the child with red-colored popsicles when oral intake is initiated.
Correct Answer: C) Administer analgesics to the child on a routine schedule throughout the
day and night.
Rationale: Effective pain management is crucial after a tonsillectomy to ensure the child can
drink fluids and avoid dehydration. Administering pain medication on a routine schedule,
rather than waiting for the child to report pain, maintains a consistent therapeutic level
and provides better pain control. Coughing (A) should be discouraged as it can cause
bleeding. A cold collar (not heat) is used (B). Red-colored fluids (D) should be avoided as
they can be mistaken for blood.
Question 6
A nurse is providing teaching to a client who has heart failure about how to reduce his daily
intake of sodium. Which of the following factors is the most important in determining the client's
ability to learn new dietary habits?
A) The involvement of the client in planning the change.
B) The emphasis the provider places on the dietary changes.
C) The learning theory the nurse uses to teach the dietary changes.
D) The extent of the dietary changes planned for the client.
,[Type here]
Correct Answer: A) The involvement of the client in planning the change.
Rationale: Adult learning principles emphasize that learning is most effective when the
learner is actively involved in the process. When a client participates in planning the
changes, they are more likely to feel a sense of ownership and control, which significantly
increases their motivation and commitment to adhering to the new plan.
Question 7
A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client.
Which of the following actions by the newly licensed nurse requires intervention?
A) Obtaining hydrogen peroxide for inner cannula care.
B) Obtaining cotton balls for cleaning the stoma.
C) Obtaining sterile gloves for the procedure.
D) Obtaining a sterile brush for the inner cannula.
Correct Answer: B) Obtaining cotton balls for cleaning the stoma.
Rationale: Cotton balls should never be used for tracheostomy care. The small fibers can
break off, be aspirated into the tracheostomy opening, and cause a tracheal abscess or
respiratory distress. Gauze pads or cotton-tipped applicators should be used instead.
Question 8
A nurse is preparing to perform mouth care for an unresponsive client. Which of the following
actions should the nurse plan to take?
A) Place the client in a supine position.
B) Keep both side rails up during the procedure.
C) Raise the level of the bed.
D) Inspect the client's mouth using a finger sweep.
Correct Answer: C) Raise the level of the bed.
Rationale: Proper ergonomics are essential to prevent back injury to the nurse. The nurse
should raise the bed to a comfortable working height before beginning any procedure. For
mouth care on an unresponsive client, the client should be positioned on their side (not
supine) to prevent aspiration, and a padded tongue blade should be used for inspection, not
a finger sweep.
Question 9
A nurse is witnessing a client sign an informed consent form for surgery. Which of the following
describes what the nurse is affirming by this action?
A) The client fully understands the provider's explanation of the procedure.
B) The client has been informed about the risks and benefits of the procedure.
C) The nurse witnessed the provider's explanation of the procedure.
D) The signature on the preoperative consent form is the client's.
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Correct Answer: D) The signature on the preoperative consent form is the client's.
Rationale: When a nurse witnesses a client's signature on a consent form, their legal role is
to attest to three things: that the person signing the form is the correct client, that the client
signed voluntarily, and that the client appeared competent to sign. It is the provider's
responsibility, not the nurse's, to ensure the client understands the procedure (A, B).
Question 10
A nurse is preparing to provide tracheostomy care for a client. Which of the following actions
should the nurse take first?
A) Open all sterile supplies and solutions.
B) Stabilize the tracheostomy tube.
C) Don sterile gloves.
D) Perform hand hygiene.
Correct Answer: D) Perform hand hygiene.
Rationale: According to the principles of medical asepsis and infection control, hand
hygiene is the first and most important step to perform before beginning any procedure.
This reduces the transmission of microorganisms. After performing hand hygiene, the
nurse can then proceed to prepare the supplies.
Question 11
A nurse is caring for an older adult client who becomes agitated when the nurse requests that the
client's dentures be removed prior to surgery. Which of the following responses should the nurse
make?
A) "It's for your safety. Dentures can slip and block your airway during surgery."
B) "You wouldn't want your teeth to be lost or broken during surgery, would you?"
C) "The anesthesiologist requires everyone to remove their dentures."
D) "What worries you about being without your teeth?"
Correct Answer: D) "What worries you about being without your teeth?"
Rationale: This is a therapeutic, open-ended question that explores the client's feelings and
concerns. The client's agitation indicates anxiety. By asking this question, the nurse
validates the client's feelings and can then address the specific fear (e.g., about
appearance), which is more effective than simply stating rules or using scare tactics.
Question 12
A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian
cancer. Which of the following statements by the client indicates she is experiencing
psychological distress?
A) "My parents are retired, and they have come to help out with our children."
B) "I am going to ask my husband to go to counseling with me."
C) "I keep having nightmares about my upcoming surgery."
D) "My girlfriends bought me a nice wig."
Complete Solutions | latest Update 2025
Question 1
A nurse is assessing the heart sounds of a client who has developed chest pain that becomes
worse with inspiration. The nurse auscultates a high-pitched scratching sound during both systole
and diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of
the following heart sounds should the nurse document?
A) Audible Click
B) Murmur
C) Third heart sound (S3)
D) Pericardial friction rub
Correct Answer: D) Pericardial friction rub
Rationale: A pericardial friction rub is a classic sign of pericarditis, an inflammation of the
sac surrounding the heart. It is described as a high-pitched, scratching, or grating sound
that is typically heard during both systole and diastole. The pain worsening with
inspiration is also a characteristic symptom of pericarditis.
Question 2
A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following
actions should the nurse take?
A) Auscultate for the blood pressure at the dorsalis pedis artery.
B) Measure the blood pressure with the client sitting on the side of the bed.
C) Place the cuff 7.6 cm (3 in) above the popliteal artery.
D) Place the bladder of the cuff over the posterior aspect of the thigh.
Correct Answer: D) Place the bladder of the cuff over the posterior aspect of the thigh.
Rationale: When measuring blood pressure in the thigh, the popliteal artery is the site for
auscultation. The bladder of the cuff must be positioned directly over this artery, which is
located on the posterior aspect of the thigh, to ensure an accurate reading. The client
should be in a prone or supine position for this measurement.
Question 3
A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly
licensed nurses. Which of the following actions should the charge nurse teach as the first
response in CPR?
A) Call for assistance.
B) Begin chest compressions.
C) Confirm unresponsiveness.
D) Give rescue breaths.
Correct Answer: C) Confirm unresponsiveness.
Rationale: According to the American Heart Association (AHA) guidelines for Basic Life
,[Type here]
Support (BLS), the first step is to assess the scene for safety and then to check for the
victim's responsiveness. You must determine if the person is unconscious and needs help
before initiating any other part of the CPR sequence.
Question 4
A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported for
the procedure, which of the following actions should the nurse take first?
A) Explain the x-ray procedure to the client.
B) Help the client into a wheelchair before the transporter arrives.
C) Ask if the client has any questions.
D) Identify the client using two identifiers.
Correct Answer: D) Identify the client using two identifiers.
Rationale: Patient safety is the top priority. The first and most critical step before any
procedure or transport is to verify the client's identity using at least two identifiers (e.g.,
name and date of birth) and comparing them to the client's wristband and the order. This
ensures that the correct client receives the correct procedure.
Question 5
A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the
following actions should the nurse take?
A) Encourage the child to cough frequently to clear congestion from anesthesia.
B) Place a heating pad on the child's neck for comfort.
C) Administer analgesics to the child on a routine schedule throughout the day and night.
D) Provide the child with red-colored popsicles when oral intake is initiated.
Correct Answer: C) Administer analgesics to the child on a routine schedule throughout the
day and night.
Rationale: Effective pain management is crucial after a tonsillectomy to ensure the child can
drink fluids and avoid dehydration. Administering pain medication on a routine schedule,
rather than waiting for the child to report pain, maintains a consistent therapeutic level
and provides better pain control. Coughing (A) should be discouraged as it can cause
bleeding. A cold collar (not heat) is used (B). Red-colored fluids (D) should be avoided as
they can be mistaken for blood.
Question 6
A nurse is providing teaching to a client who has heart failure about how to reduce his daily
intake of sodium. Which of the following factors is the most important in determining the client's
ability to learn new dietary habits?
A) The involvement of the client in planning the change.
B) The emphasis the provider places on the dietary changes.
C) The learning theory the nurse uses to teach the dietary changes.
D) The extent of the dietary changes planned for the client.
,[Type here]
Correct Answer: A) The involvement of the client in planning the change.
Rationale: Adult learning principles emphasize that learning is most effective when the
learner is actively involved in the process. When a client participates in planning the
changes, they are more likely to feel a sense of ownership and control, which significantly
increases their motivation and commitment to adhering to the new plan.
Question 7
A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client.
Which of the following actions by the newly licensed nurse requires intervention?
A) Obtaining hydrogen peroxide for inner cannula care.
B) Obtaining cotton balls for cleaning the stoma.
C) Obtaining sterile gloves for the procedure.
D) Obtaining a sterile brush for the inner cannula.
Correct Answer: B) Obtaining cotton balls for cleaning the stoma.
Rationale: Cotton balls should never be used for tracheostomy care. The small fibers can
break off, be aspirated into the tracheostomy opening, and cause a tracheal abscess or
respiratory distress. Gauze pads or cotton-tipped applicators should be used instead.
Question 8
A nurse is preparing to perform mouth care for an unresponsive client. Which of the following
actions should the nurse plan to take?
A) Place the client in a supine position.
B) Keep both side rails up during the procedure.
C) Raise the level of the bed.
D) Inspect the client's mouth using a finger sweep.
Correct Answer: C) Raise the level of the bed.
Rationale: Proper ergonomics are essential to prevent back injury to the nurse. The nurse
should raise the bed to a comfortable working height before beginning any procedure. For
mouth care on an unresponsive client, the client should be positioned on their side (not
supine) to prevent aspiration, and a padded tongue blade should be used for inspection, not
a finger sweep.
Question 9
A nurse is witnessing a client sign an informed consent form for surgery. Which of the following
describes what the nurse is affirming by this action?
A) The client fully understands the provider's explanation of the procedure.
B) The client has been informed about the risks and benefits of the procedure.
C) The nurse witnessed the provider's explanation of the procedure.
D) The signature on the preoperative consent form is the client's.
, [Type here]
Correct Answer: D) The signature on the preoperative consent form is the client's.
Rationale: When a nurse witnesses a client's signature on a consent form, their legal role is
to attest to three things: that the person signing the form is the correct client, that the client
signed voluntarily, and that the client appeared competent to sign. It is the provider's
responsibility, not the nurse's, to ensure the client understands the procedure (A, B).
Question 10
A nurse is preparing to provide tracheostomy care for a client. Which of the following actions
should the nurse take first?
A) Open all sterile supplies and solutions.
B) Stabilize the tracheostomy tube.
C) Don sterile gloves.
D) Perform hand hygiene.
Correct Answer: D) Perform hand hygiene.
Rationale: According to the principles of medical asepsis and infection control, hand
hygiene is the first and most important step to perform before beginning any procedure.
This reduces the transmission of microorganisms. After performing hand hygiene, the
nurse can then proceed to prepare the supplies.
Question 11
A nurse is caring for an older adult client who becomes agitated when the nurse requests that the
client's dentures be removed prior to surgery. Which of the following responses should the nurse
make?
A) "It's for your safety. Dentures can slip and block your airway during surgery."
B) "You wouldn't want your teeth to be lost or broken during surgery, would you?"
C) "The anesthesiologist requires everyone to remove their dentures."
D) "What worries you about being without your teeth?"
Correct Answer: D) "What worries you about being without your teeth?"
Rationale: This is a therapeutic, open-ended question that explores the client's feelings and
concerns. The client's agitation indicates anxiety. By asking this question, the nurse
validates the client's feelings and can then address the specific fear (e.g., about
appearance), which is more effective than simply stating rules or using scare tactics.
Question 12
A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian
cancer. Which of the following statements by the client indicates she is experiencing
psychological distress?
A) "My parents are retired, and they have come to help out with our children."
B) "I am going to ask my husband to go to counseling with me."
C) "I keep having nightmares about my upcoming surgery."
D) "My girlfriends bought me a nice wig."
