CMSRN practice questions, weighted like the real blueprint

A client with severe COPD is acutely wheezing and dyspneic. Which prescribed medication should the nurse give first for immediate relief?

Use Check on the answer you favor. The verdict shows up with a short note on each choice.

1. Inhaled salmeterol
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   Salmeterol is a long-acting beta-agonist for maintenance; its slow onset makes it wrong for immediate relief.
2. Oral montelukast
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   Montelukast is a leukotriene modifier for long-term control and does nothing for an acute attack.
3. Nebulized albuterol
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   Albuterol is a short-acting beta-agonist that opens the airways within minutes, so it is the rescue drug in acute bronchospasm.
4. Oral prednisone
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   Oral prednisone treats the inflammation of an exacerbation, but its effect takes hours, so it follows the bronchodilator.

A client on a telemetry unit is prescribed an amiodarone maintenance infusion at 0.5 mg/min. The bag contains 900 mg of amiodarone in 500 mL of D5W. At what rate should the nurse set the pump?

1. 0.3 mL/hr
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   0.3 mL is the volume needed each minute (0.5 ÷ 1.8 ≈ 0.28); leaving out the × 60 sets the pump far too low.
2. 8.3 mL/hr
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   8.3 mL/hr assumes 3.6 mg/mL, as if the 900 mg were in 250 mL, which halves the rate.
3. 30.0 mL/hr
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   30.0 mL/hr enters the hourly dose in milligrams as if it were milliliters, skipping the concentration step.
4. 16.7 mL/hr
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   The bag holds 900 mg ÷ 500 mL = 1.8 mg/mL; 0.5 mg/min × 60 = 30 mg/hr, and 30 ÷ 1.8 = 16.7 mL/hr.

A client with GERD is prescribed a proton pump inhibitor. Which instruction should the nurse provide?

1. Take it before breakfast each morning
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   Proton pump inhibitors block pumps that food activates, so a dose taken before the first meal gives the strongest acid suppression.
2. Take it only on days when heartburn occurs
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   Taking it only on heartburn days undertreats GERD; the drug needs regular daily dosing to control acid.
3. Lie down for a short rest after each meal
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   Lying down after a meal lets stomach contents flow back into the esophagus; clients stay upright for a few hours after eating.
4. Have the largest meal close to bedtime
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   A large meal close to bedtime fills the stomach just before the client lies flat, a classic reflux trigger.

A client had a percutaneous endoscopic gastrostomy (PEG) tube placed 48 hours ago and feedings have started. Which finding requires the nurse to stop the feeding and notify the provider?

1. Rigid abdomen with pain during feeding
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   Before the tract matures a displaced tube can leak formula into the peritoneum; a rigid abdomen with pain during feeding suggests peritonitis.
2. A gastric residual volume of 150 mL
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   A residual of 150 mL with no other sign of intolerance does not justify stopping feeds under current practice.
3. Mild tenderness at the insertion site
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   Mild tenderness at a 2-day-old insertion site is expected while the tissue heals.
4. Scant clear drainage on the stoma gauze
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   A scant amount of clear drainage on the gauze is normal in the first days after placement.

A nurse notes early signs that a client may be deteriorating. Which action should the nurse take first?

1. Have the UAP repeat vital signs in an hour
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   Handing the check to the UAP and waiting an hour delays recognition; early signs of decline need the nurse's own assessment now.
2. Document the concern and continue routine care
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   Documenting the concern without acting on it leaves a declining client without assessment or escalation.
3. Check vital signs and do a focused assessment
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   A quick set of vital signs and a focused assessment show how unstable the client is and supply the data any escalation will rely on.
4. Increase the IV fluid rate as a precaution
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   Raising the IV fluid rate without an order or an assessment treats a problem that has not been identified.

A nurse finds a client's daughter pressing the PCA button while the client sleeps 'so he won't wake up in pain.' Which action should the nurse take?

1. Let her keep pressing it for him
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   The daughter means well, but letting her keep pressing for a sleeping client bypasses the sedation check built into PCA.
2. Explain that only he may activate a dose
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   PCA is safe because a client who becomes too sedated stops pressing; when a visitor activates doses for a sleeping client, that safeguard is gone.
3. Increase the basal rate on the pump
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   Raising the basal rate adds continuous opioid without an order and increases the risk of oversedation in a client already asleep.
4. Switch the PCA to PRN intramuscular injections
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   Intramuscular injections absorb erratically and hurt, and switching the route needs a prescriber, not a nursing decision.

A code blue is called for a client on a medical-surgical unit, and the client's primary nurse is at the bedside. Which action by the charge nurse best maintains safe care for the rest of the unit?

1. Reassign the primary nurse's other clients
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   The primary nurse is tied up at the code, so moving that nurse's other clients to available nurses keeps their care going.
2. Adjust assignments after the code ends
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   A code can run long, and that nurse's clients go without a nurse until assignments are adjusted after it ends.
3. Ask the UAP to monitor the other clients
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   A UAP can take vital signs but cannot assess or make nursing judgments, so those clients would still lack nursing care.
4. Send every available RN on the unit to the code
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   Sending every RN to one room leaves the rest of the unit unattended; the code team brings its own responders.

An agency nurse arrives for her first shift on a medical-surgical unit. Which action should the charge nurse take before giving her an assignment?

1. Ask staff to recheck all of her work today
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   Having staff recheck every task is impractical on a busy unit and does not establish that she is qualified.
2. Give her the lightest assignment without checks
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   Even the lightest assignment is unsafe if no one has confirmed her license and skills.
3. Verify her license and validated competencies
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   Confirming an active license and documented competencies that match the unit's clients is the basis for a safe first assignment.
4. Have her shadow a staff nurse for the whole shift
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   Shadowing a whole shift leaves a qualified nurse unused when the unit needs her; a brief unit orientation suffices once credentials are verified.

A nurse manager is guiding the unit through a practice change. Which strategy best promotes effective change management?

1. Roll out every change at once without a plan
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   Rolling out everything at once with no plan overwhelms staff and makes it impossible to tell which part caused a problem.
2. Follow another unit's process without adapting it
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   Another unit's process reflects its own workflow; adopting it unchanged ignores this unit's staff, patients, and layout.
3. Track measurable goals at set checkpoints
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   Measurable goals and scheduled checkpoints show whether the change is working and allow adjustment before small problems grow.
4. Wait for problems to surface before acting
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   Waiting for problems is reactive, and by the time they surface staff have often lost confidence in the change.

A preceptor is evaluating whether an orientee can safely manage a full assignment. Which evaluation method is most effective?

1. Check only whether tasks were completed
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   A finished task list says nothing about the quality of care or whether the orientee recognized problems along the way.
2. Observe care and discuss the reasoning
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   Observing care and discussing the reasoning behind each decision reveals both skill and clinical judgment, the two things a full assignment demands.
3. Rely only on a written test of unit policies
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   A written policy test measures recall, not the ability to prioritize and act with several clients at once.
4. Wait for a patient or family complaint
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   Waiting for a complaint means harm has often happened before the gap is noticed.

An RN plans to delegate ambulation to an unlicensed assistive personnel (UAP). For which client is this delegation inappropriate?

1. A client with orthostatic BP this morning
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   An orthostatic drop this morning makes the response to standing unpredictable, so the RN assesses and walks this client first.
2. A client 3 days post-op with stable vitals
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   Three days after surgery with stable vitals, this client's response to walking is predictable enough to delegate.
3. A client who uses a walker at baseline
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   Using a walker at baseline is a known, stable routine that a trained UAP can support.
4. A client who walked three times yesterday
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   A client who walked safely three times yesterday has shown a predictable response, which supports delegation.

A client needing symptom management and lacking transportation is being discharged to hospice. What is the correct sequence of nursing actions?

1. Arrange transport before the symptom plan
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   Booking transport before the symptom plan risks the client leaving with pain or breathlessness that no one has planned for.
2. Secure the symptom plan, then equipment and transport
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   Uncontrolled symptoms are the biggest threat on the way home, so the symptom plan comes first, followed by the equipment and the ride.
3. Order equipment after the family leaves
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   The family needs to see and learn the equipment; ordering it after they leave delays setup and teaching.
4. Schedule home services after the discharge is complete
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   Services scheduled after discharge leave a gap just when a hospice client is most fragile.

A nurse starts the shift and sees four clinical decision support alerts. Which alert requires the MOST urgent nursing action?

1. Lactate 2.8 mmol/L; HR 112/min, day 2 after bowel surgery
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   A lactate above 2 mmol/L with tachycardia after bowel surgery suggests hypoperfusion from sepsis or an anastomotic leak, a time-critical problem.
2. Fall-risk score 45; bed alarm on and the client is asleep
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   The fall-risk alert already has its intervention in place, and the client is asleep with the bed alarm on.
3. Hemoglobin 9.8 g/dL; it was 10.1 g/dL yesterday
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   A hemoglobin drop of 0.3 g/dL is within normal lab variation and needs trending, not urgent action.
4. Potassium 5.2 mEq/L; client receiving scheduled oral potassium
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   A potassium of 5.2 in a client on supplements means holding the next dose and informing the provider, but it is not immediately dangerous.

A client is transferring from the medical-surgical unit to interventional radiology for a procedure. Which action by the nurse most directly maintains continuity of care?

1. Complete the transfer checklist in the record
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   A completed transfer checklist shows steps were ticked off but does not ensure the receiving clinicians hear the clinical details.
2. Hand off drugs, allergies, and the indication
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   Passing on current drugs, allergies, and why the procedure is being done gives the receiving team what it needs to keep care safe and continuous.
3. Confirm the belongings are labeled and packed
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   Labeling belongings prevents loss but has no effect on the client's clinical safety during the procedure.
4. Notify the transport team of the pickup time
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   Setting the pickup time with transport is logistics; it moves the client but carries none of the clinical information.

A client is unsure about a recommended procedure and does not understand the alternatives. Which nursing action best demonstrates patient advocacy?

1. Defer all decisions to the healthcare providers
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   Deferring every decision to providers removes the client from a choice that belongs to the client.
2. Follow the family's wishes instead of the client's
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   The family's wishes do not replace those of a client who can decide; the nurse brings the client's own voice forward.
3. Review the client's rights and options with them
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   Reviewing rights and options with the client is advocacy: the client can then make their own decision, and the nurse can ask the provider to explain alternatives again.
4. Make the decision on the client's behalf
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   Making the decision for the client is paternalism, the opposite of advocacy.

A client on a strict 2-gram sodium diet for heart failure has family bringing in heavily salted traditional foods they consider essential for healing. Which intervention best demonstrates cultural humility while maintaining safety?

1. Allow the foods while increasing the diuretic dose
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   Changing the diuretic dose is not a nursing decision, and more diuretic does not make high-sodium foods safe for a failing heart.
2. Confiscate the salted foods and explain the diet policy
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   Confiscating the salted foods treats the family's tradition as a rule violation and damages the trust that diet teaching needs.
3. Tell the family all outside food is prohibited
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   A blanket ban on outside food ignores the culture behind it and invites the family to bring it in anyway.
4. Help the family adapt the recipes to fit the diet
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   Adapting the recipes with the family honors what the food means to them while keeping the client within the 2-gram limit.

A nurse is preparing to reposition and clean an incontinent client in a shared room. Which action best promotes the client's dignity?

1. Give privacy and honor the client's wishes
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   Giving privacy and honoring how the client wishes care to be done protects dignity, especially in a shared room.
2. Let other staff and visitors watch the care
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   Letting onlookers watch incontinence care without consent violates privacy and dignity.
3. Finish the task as quickly as possible
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   Rushing to finish feels rough and impersonal and does nothing for privacy; dignity comes from respect, not speed.
4. Follow the standard routine without individualizing
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   A standard routine ignores what this client wants, such as the order of care or who assists.

A nurse is caring for a client receiving palliative care whose adult children want to help with daily care but are unsure of their role. Which nursing action best supports appropriate family involvement?

1. Teach the family safe tasks that fit the client's wishes
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   Teaching the children safe tasks that fit what the client wishes lets them help and keeps care consistent and safe.
2. Ask the family to step out while staff complete all care
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   Asking the family to step out shuts them out of care they want to give and that the client values at the end of life.
3. Give the family full charge of hygiene and feeding
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   Handing the family full charge of hygiene and feeding shifts the nurse's accountability to untrained relatives and puts the client at risk, for example with swallowing.
4. Let the family give any care they choose
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   Unguided care can conflict with the client's wishes and the plan, and the family has said they are unsure of their role.

A nurse sees a colleague repeatedly skipping hand hygiene for a client on contact precautions. What is the best immediate action?

1. Correct the colleague publicly at the bedside
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   Correcting the colleague publicly in front of the client embarrasses both and damages trust; the immediate stop can be done discreetly.
2. Document the incidents without speaking to anyone
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   Documenting silently lets the breach continue while the client stays exposed.
3. Tell the charge nurse at the end of the shift
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   Waiting until the end of the shift to tell the charge nurse allows many more contacts without hand hygiene.
4. Speak up now, then give private feedback
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   Speaking up at once stops the next missed hand hygiene, and private, nonjudgmental feedback afterward changes behavior without shaming.

A client's early-warning score in the clinical decision support system is low, yet the bedside exam shows deterioration. What is the best immediate action?

1. Recheck the score at the next vital signs
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   Rechecking the score at the next vital signs delays care while the client is visibly declining.
2. Escalate per protocol and document
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   Decision support is advisory; the bedside findings drive action, so the nurse escalates under the protocol and records what was seen.
3. Chart the decline and wait for the score to rise
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   Charting the decline without escalating leaves the client untreated until a number catches up with the exam.
4. Trust the CDS score and continue monitoring
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   A low CDS score reflects only the data entered; trusting it over a worsening exam is how deterioration gets missed.

An oncoming nurse is receiving handoff on a client with a new chest tube. Which action by the oncoming nurse best completes a safe handoff?

1. Rely on the EHR summary instead of report
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   The EHR summary can lag behind what happened during the shift and cannot answer follow-up questions.
2. Take notes and review them after rounds
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   Reviewing notes after rounds is too late to clarify anything with the nurse who gave report.
3. Read back key points and ask questions
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   Reading back the main points and asking questions while the off-going nurse is still present catches misunderstandings about the chest tube and plan.
4. Take report at the nurses' station
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   Report at the nurses' station misses the chance to check the chest tube system and drainage together at the bedside.

A PDSA cycle targets medication safety. Which measure is appropriate for short-cycle testing?

1. Process compliance rate
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   A process measure such as compliance with a new step changes quickly and shows within days whether the test of change is working.
2. Number of sentinel events
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   Sentinel events are rare, so a short cycle almost never sees enough of them to detect an effect.
3. Overall hospital mortality
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   Overall hospital mortality is driven by many factors and moves too slowly to reflect a small unit test.
4. Annual staff turnover rate
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   Annual staff turnover is unrelated to medication safety and changes over months, not over a short cycle.

A routine urine culture for an older client grows more than 100,000 colonies of E. coli. The client has no fever, dysuria, or change in mental status. Which action is appropriate?

1. Push oral fluids to 3 L per day
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   Pushing 3 L of fluid a day does not clear colonization and can overload an older adult with heart or kidney limits.
2. Place an indwelling urinary catheter
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   An indwelling catheter is the leading cause of hospital urinary infections and has no role in managing a positive culture alone.
3. Request an antibiotic for the culture result
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   An antibiotic for the culture result alone does not prevent sepsis; it adds resistance, side effects, and C. difficile risk, which stewardship guidance avoids.
4. Continue monitoring without antibiotics
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   Monitoring without antibiotics fits asymptomatic bacteriuria, a positive culture without symptoms that is common in older adults and not treated; the nurse keeps watching for fever, dysuria, or confusion.

A client on postoperative day 2 after abdominal surgery has a Jackson-Pratt drain. Which action by the nurse is correct?

1. Irrigate the drain with saline if output drops.
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   Irrigating a surgical drain needs a specific order and opens the system to infection; falling output is reported, not flushed.
2. Keep the bulb fully expanded between emptyings.
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   A fully expanded bulb has no suction, so fluid pools in the wound instead of draining.
3. Record the output only when changing the dressing.
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   Output is recorded every time the drain is emptied, because changes in amount or color are early signs of bleeding or a leak.
4. Empty it when half full, then recompress the bulb.
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   A Jackson-Pratt drain works by suction, so it is emptied before it is more than half full and the bulb is squeezed flat before the plug is closed.

A client started on scheduled oxycodone after a spinal fusion has no bowel regimen ordered. The client has not had a bowel movement in 2 days. Which action by the nurse is most appropriate?

1. Request a bulk-forming fiber supplement alone
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   A bulk-forming fiber supplement alone adds volume to a slowed bowel and, without generous fluids, can harden stool toward impaction.
2. Request a stimulant laxative with a stool softener
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   Opioids slow bowel motility and tolerance to this effect does not develop, so a stimulant laxative, often with a softener, is the standard regimen the nurse requests from the prescriber.
3. Hold the oxycodone until a bowel movement occurs
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   Holding the oxycodone after a spinal fusion leaves pain uncontrolled; the fix is treating the constipation, not stopping the analgesic.
4. Wait until 3 days pass before contacting the provider
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   Waiting until 3 days pass before contacting the provider lets constipation worsen when a scheduled opioid is already known to cause it.

A client's parenteral nutrition bag is nearly empty, and pharmacy reports the next bag will not be ready for 3 hours. Which action should the nurse take?

1. Hang 0.9% sodium chloride at the same rate
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   Sodium chloride at the same rate keeps the line open but supplies no glucose, so blood sugar still drops.
2. Hang 10% dextrose at the same rate
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   Parenteral nutrition carries concentrated dextrose and the body's insulin output is matched to it, so 10% dextrose at the same rate bridges the gap and prevents rebound hypoglycemia.
3. Stop the infusion until the next bag
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   Stopping the infusion for 3 hours risks rebound hypoglycemia while insulin levels are still high.
4. Flush and lock the line for now
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   Flushing and locking the line is the same abrupt stop in another form, with the same risk of hypoglycemia.

A charge nurse is deciding which task to assign an experienced LPN. Which task is within the LPN's scope of practice?

1. Creating the client's nursing care plan
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   Creating the care plan rests on the RN's comprehensive assessment and stays with the RN.
2. Evaluating the client's response to care
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   Evaluating the client's response to care judges whether the plan works, the RN step that closes the nursing process.
3. Performing the initial admission assessment
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   The initial admission assessment sets the baseline for all later care and is an RN responsibility; an LPN collects data that supports it.
4. Reinforcing standard teaching for a stable client
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   LPNs reinforce teaching that the RN has planned, and a stable client with routine needs fits that role.

A client with a new colostomy is otherwise independent in self-care, but the pouch has leaked three times and the skin around the stoma is red and weeping. Which referral should the nurse request?

1. Occupational therapist for hand skills
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   The client is independent in self-care, so the hand skills an occupational therapist works on are not the cause of the leaks.
2. Dietitian for ostomy diet teaching
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   Ostomy diet teaching shapes output and gas, but diet does not fix a leaking seal or treat the damaged skin around the stoma.
3. Social worker for ostomy supply coverage
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   A social worker can help pay for ostomy supplies, but coverage neither fixes a pouch seal that keeps failing nor heals the weeping skin.
4. Wound, ostomy, and continence nurse
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   Repeated leaks with damaged peristomal skin point to a poor pouch fit or technique, which the wound, ostomy, and continence nurse assesses, resizes, and treats.

A client's home list has metoprolol succinate 50 mg once daily; the discharge list, confirmed by the provider, has metoprolol tartrate 25 mg twice daily. The client's daughter fills his weekly pillbox. Which action is MOST important before discharge?

1. Ask the daughter to use up the old bottle first
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   Using up the old bottle keeps the client on the discontinued product and schedule, the very error reconciliation is meant to stop.
2. Mail the updated list to the primary care provider
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   Mailing the list to the primary care provider supports follow-up but does nothing about a pillbox error this week.
3. Teach the daughter the new tablets and schedule
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   The daughter fills the pillbox, so she has to remove the once-daily tablets and set up twice-daily doses, or the client ends up taking both forms or the wrong schedule.
4. Tell the client the two forms are interchangeable
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   Succinate is extended-release taken once daily and tartrate is immediate-release taken twice daily, so the forms are not interchangeable one-for-one.

A client is going home after a total hip arthroplasty by the posterior approach, and the surgeon has ordered hip precautions. Which statement by the client indicates a need for more teaching?

1. I'll keep a pillow between my knees in bed.
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   A pillow between the knees in bed keeps the leg from crossing the midline, which protects the posterior hip; this plan is safe.
2. I'll use a raised toilet seat at home.
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   A raised toilet seat keeps hip flexion under 90 degrees when sitting down, so this plan follows the precautions.
3. I'll relax in my low recliner at home.
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   Sinking into a low recliner bends the hip past 90 degrees, which can dislocate a posterior-approach implant, so this statement shows the teaching did not take.
4. I'll use a reacher to pick things up.
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   A reacher lets the client pick things up without bending forward at the hip, which the precautions require.