Free CMSRN Practice Test 2026 — Medical-Surgical Nurse

Transitioning a patient from continuous enteral support to oral intake requires careful coordination to prevent nutritional deficits. Because the patient is recovering from a severe stroke and is now cleared for a pureed diet, they need a structured plan to ensure they consume adequate calories orally before the tube feeding is completely removed. Option C is correct because the registered dietitian is uniquely qualified to calculate calorie counts and design a safe transitional weaning schedule. Option A is dangerous because abruptly stopping the feeding before proving adequate oral intake risks rapid malnutrition. Option B is incorrect because maintaining a continuous rate while eating often causes fullness, nausea, and poor oral intake. Option D is incorrect because while speech therapy determines the safe diet texture, the dietitian manages the caloric weaning process.

Erythema extending beyond one inch combined with a palpable cord indicates grade 3 phlebitis. The standard of care requires immediate catheter removal and the application of a warm moist compress to relieve pain and inflammation. Option A is incorrect because grade 3 phlebitis requires active intervention, not just ongoing monitoring. Option C is incorrect because flushing a phlebitic vein causes severe pain and can push potential microthrombi into the patient's systemic circulation. Option D is incorrect because while elevation and analgesics might provide comfort, they do not address the primary source of the inflammation, which is the catheter itself.

Some older adults with intact cognition find the numeric rating scale too abstract. When a patient struggles to assign a number, the nurse should switch to a verbal descriptor scale, which uses familiar words like "aching" or "severe" to measure intensity. It is incorrect to document an inability to self-report or use a behavioral tool like the PAINAD scale, as the patient is cognitively intact. Repeatedly explaining the numeric scale causes frustration without improving assessment accuracy.

When a patient undergoes multiple procedures performed by different teams, a separate time-out must be conducted before each specific procedure begins to ensure accurate communication among the new team members. A single comprehensive time-out at the beginning is insufficient because the second team may not be present or focused, making the first option incorrect. While the circulating nurse often facilitates, a combined time-out fails to address the distinct safety checks required for the second team's procedure, eliminating the third option. One surgeon cannot vouch for a procedure they are not performing, making the final option incorrect.

Administering high-alert medications requires careful diagnostic formulation to ensure patient safety. Because the patient has advanced kidney disease, their impaired excretion capabilities make intravenous potassium highly dangerous, prioritizing "Risk for Electrolyte Imbalance." Excess Fluid Volume (Option B) and Impaired Urinary Elimination (Option D) are standard chronic diagnoses for this population, but they don't address the acute, immediate threat posed by the potassium infusion. Risk for Decreased Cardiac Output (Option C) is a potential consequence if hyperkalemia develops and causes dysrhythmias, but the electrolyte imbalance is the primary, direct risk that nursing interventions must target first.

The patient has a significant risk for injury due to polypharmacy and a history of falls. When an older adult takes numerous medications, the risk for adverse drug events and interactions increases exponentially, making a comprehensive medication reconciliation the most critical assessment for identifying the root cause of the falls. Option A is incorrect because while evaluating gait is helpful, it only identifies the physical deficit rather than the underlying pharmacological cause. Option C is incorrect because an environmental check addresses external hazards but ignores the systemic internal risks posed by twelve medications. Option D is incorrect because assessing orthostatic changes is only one narrow component of a fall assessment, whereas reviewing the entire medication profile provides a broader understanding of the patient's overall safety risk and potential toxicities.

An S3 gallop is a low-pitched sound indicating ventricular volume overload, which is best auscultated using the stethoscope bell placed lightly over the cardiac apex while the patient is in the left lateral decubitus position. The diaphragm is designed to pick up high-pitched sounds like normal S1 and S2 or murmurs, making it ineffective for an S3. Placing the stethoscope at the aortic or pulmonic areas targets the base of the heart, which is ideal for assessing semilunar valve pathology rather than ventricular filling sounds. The lower sternum is the tricuspid area, which is less optimal than the apex for detecting left-sided ventricular volume overload.

The patient is receiving continuous intravenous fluids and has developed a new dry, hacking cough, which is an early clinical indicator of fluid volume overload and impending pulmonary edema. Auscultating the lung bases for fine crackles is the most direct assessment technique to evaluate this specific safety threat. Option A is incorrect because while bounding pulses indicate fluid volume excess, they do not provide immediate data regarding the patient's respiratory compromise. Option B is incorrect because measuring urine output evaluates renal perfusion and fluid balance but does not assess the acute respiratory changes causing the cough. Option D is incorrect because assessing the oral mucosa evaluates for dehydration, which contradicts the clinical picture of a patient receiving continuous fluids who is likely experiencing pulmonary fluid accumulation.

When performing a comprehensive abdominal assessment, auscultation must always follow inspection and precede percussion or palpation. Touching or pressing on the abdomen can stimulate peristalsis, potentially creating false bowel sounds and masking the true clinical picture of a suspected obstruction. While palpating for tenderness and percussing for dullness are important steps to identify masses or fluid, doing them prematurely alters the auscultatory findings. Measuring abdominal girth is a valuable tracking metric for distention, but establishing the baseline bowel sound characteristics takes immediate clinical precedence to determine if an acute mechanical obstruction is present.

The patient has a low hemoglobin level from a recent bleed and is experiencing dizziness upon standing, which strongly suggests a drop in cerebral perfusion. Measuring orthostatic blood pressure is the most appropriate assessment technique to confirm this safety risk and guide mobilization strategies. Option B is incorrect because a focused neurological exam evaluates for structural brain issues or stroke, which does not align with the systemic symptoms of anemia and position changes. Option C is incorrect because evaluating stool for occult blood helps identify the source of the bleed but does not assess the patient's immediate risk for falls and injury. Option D is incorrect because assessing capillary refill provides information about general peripheral perfusion but does not capture the hemodynamic shifts that occur when the patient changes position.

Intravenous furosemide induces rapid diuresis, frequently leading to intravascular volume depletion and orthostatic hypotension. For an older adult who already requires an assistive device, this sudden hemodynamic shift creates an acute, high-risk fall scenario. Checking orthostatic vital signs directly evaluates this immediate physiological threat before the patient stands. Evaluating muscle strength and observing baseline gait are standard mobility assessments, but they do not capture the acute medication-induced risk of hemodynamic instability. Reviewing potassium levels is necessary because loop diuretics cause hypokalemia, but a potassium shift will not cause an immediate syncopal fall during mobilization as rapidly as a drop in blood pressure will.

A patient with a recent stroke who clears their throat frequently during meals is exhibiting classic signs of dysphagia and silent aspiration. Observing the swallowing mechanism directly is the most functional and accurate assessment technique to determine the patient's airway safety. Option A is incorrect because auscultating bowel sounds evaluates gastrointestinal motility, which is unrelated to the immediate upper airway and swallowing risks. Option B is incorrect because while articulation requires some of the same musculature, clear speech does not guarantee a safe swallow. Option D is incorrect because assessing the gag reflex is an unreliable indicator of aspiration risk; many healthy individuals lack a gag reflex, and its presence does not ensure that the airway is adequately protected during the complex physiological process of swallowing food or liquids.

The patient's presentation strongly suggests acute compartment syndrome, a surgical emergency where tissue pressure exceeds perfusion pressure. The earliest and most sensitive assessment finding is severe pain with passive stretch of the digits. Palpating pulses and assessing capillary refill are standard vascular checks, but they are notoriously late indicators; arterial flow often remains intact until tissue ischemia is already severe, explaining why the toes are still warm and pink. Measuring the leg's circumference is impractical because the rigid cast prevents direct access and restricts outward swelling, which is the exact mechanism causing the internal tissue pressure to rise.

Patient safety objectives prioritize airway protection above all else. The clinical cues of coughing and a wet voice strongly indicate that fluids are entering the airway, making "Risk for Aspiration" the most critical safety diagnosis. Impaired Swallowing (Option A) is an accurate actual diagnosis, but it does not emphasize the life-threatening consequence of the impairment like the aspiration risk does. Ineffective Airway Clearance (Option C) implies an inability to clear existing secretions, but the primary issue here is preventing food and fluid from entering the lungs. Risk for Infection (Option D) is a secondary downstream complication of aspiration, not the immediate safety priority.

Option B is correct because the patient's attempts to climb out of bed and pull at lines present an immediate physical safety hazard driven by an acute altered mental status likely secondary to urosepsis. Option A is incorrect because the primary issue is unsafe, uncoordinated movement rather than a simple lack of mobility. Option C is incorrect because while urosepsis implies fluid needs, the behavioral cues require immediate injury prevention. Option D is incorrect as standard precautions manage transmission, making the immediate fall risk the higher priority.

When analyzing data for a severely neutropenic patient, recognizing the immunocompromised state is vital for patient safety. An ANC of 400 combined with an invasive line creates a profound vulnerability to systemic pathogens, making "Risk for Infection" the priority diagnosis. Impaired Skin Integrity (Option A) is present at the insertion site, but the systemic infection risk is the larger safety threat. Risk for Bleeding (Option B) might be a concern if platelets were mentioned, but the cues specifically highlight low neutrophils. Ineffective Protection (Option D) is a valid broader diagnosis, but Risk for Infection specifically directs the nurse to implement protective isolation and manage primary defenses.

Succession planning for charge nurses requires identifying individuals who demonstrate both clinical competence and informal leadership, such as teamwork and peer support. A nurse who frequently assists peers with complex discharges shows proactive collaboration, which is a foundational trait for a charge nurse. Consistently completing tasks independently is excellent for a staff nurse but lacks the relational leadership required for a charge role. While a graduate degree is helpful, it does not automatically translate to practical clinical leadership or peer influence on the unit. Volunteering for overtime shows dedication to the unit but does not necessarily indicate leadership capacity or the ability to manage team dynamics.

The charge nurse facilitates discharges by collaborating with the interdisciplinary team to resolve barriers. Contacting the case manager to find an alternative vendor addresses the equipment delay while promoting timely patient flow. Discharging the patient without required oxygen compromises patient safety and violates the discharge plan. Transferring a medically cleared patient to the intensive care unit is an inappropriate use of critical care resources. Revoking the discharge order unnecessarily extends the hospital stay when a logistical solution might be available today.

In a shared governance model, clinical practice decisions are decentralized, empowering staff nurses through the unit practice council to develop and approve evidence-based protocols. Option B reflects a centralized, top-down hierarchy rather than shared governance. Option C incorrectly assigns clinical practice approval to an administrative manager, whose role is operational rather than clinical standard-setting. Option D focuses on enforcement and education rather than the collaborative development and approval characteristic of this organizational structure.

A scenario-based pretest is the best way because it objectively measures baseline knowledge across all experience levels before rolling out a complex new protocol. Reviewing orientation checklists only assesses the new graduates and ignores the veteran staff who also need to learn the new protocol. Asking charge nurses for evaluations yields subjective data rather than measurable knowledge gaps. Analyzing past compliance reflects adherence to old protocols, not knowledge of the upcoming complex changes.

The right circumstance dictates that delegation is only appropriate when the patient is stable and the clinical context is safe. A patient with new-onset atrial fibrillation and a heart rate of 135 bpm is an unstable patient at high risk for dizziness, syncope, and decreased cardiac output. Ambulating this patient poses a significant safety risk and requires an RN's continuous assessment. Options B, C, and D are appropriate delegations; an LPN can safely administer oral medications and perform an ECG, while a UAP can safely record fluid intake without compromising patient safety during an acute cardiac event.

Administering scheduled oral medications falls safely within the LPN's scope of practice. The RN cannot delegate tasks that involve the core nursing process, such as evaluation or initial patient education. Option A is incorrect because evaluating a patient's self-care ability requires RN-level clinical judgment. Option B is incorrect because applying a new wafer to a fresh, two-day-old stoma requires assessment of the peristomal skin and stoma viability, which is beyond the UAP's scope. Option D is incorrect because teaching is an RN responsibility and cannot be delegated to a UAP.

The right task principle dictates that delegated tasks must not require complex nursing judgment and must have a low potential for harm. Measuring blood pressure on an arm with a newly placed arteriovenous fistula can cause severe vascular damage, thrombosis, and loss of the dialysis access. Delegating this to a UAP violates the right task and the right circumstance because it places the patient at significant risk. Options B, C, and D are all appropriate delegations; LPNs can safely administer oral medications and gather physical assessment data like lung sounds, while UAPs can safely obtain daily weights.

Providing clear expectations is a cornerstone of the right direction and communication. Option D is the best choice because it specifies the timing (before breakfast) and provides a concrete parameter for reporting abnormal findings (a two-pound gain), which is critical for a heart failure patient. Options A and B provide timing and method but fail to instruct the UAP on what data needs to be immediately reported to the RN. Option C includes a reporting instruction, but "any changes" is too subjective and lacks the specific numerical threshold needed for safe delegation.

Although the patient passed a swallow screen, the acute ischemic stroke and right-sided facial weakness make the first meal a high-risk situation requiring RN evaluation. Delegating the feeding to a UAP is unsafe because UAPs cannot assess swallowing tolerance. Having the UAP simply set up the tray ignores the patient's need for feeding assistance and monitoring. UAPs do not determine diet modifications like pureeing food.

When a UAP reports abnormal vital signs, the RN must personally assess the patient to determine the clinical significance and required interventions. Delaying care by having the UAP recheck the vital signs ignores a potentially acute decline. Delegating oxygen administration is inappropriate as oxygen is a medication requiring an order and RN assessment. While elevating the bed is helpful, it does not replace the mandatory assessment.

Many insurance plans, including traditional Medicare, require a three-day qualifying stay in an acute care hospital before covering subacute or skilled nursing facility care. The nurse must collaborate with case management and the provider to safely delay the transfer, ensuring the patient meets coverage criteria without facing unexpected financial burdens. Transferring the patient and billing the family for the shortage is unethical and bypasses proper care coordination. Changing the order to an acute rehabilitation facility is inappropriate because acute rehab requires different clinical criteria, such as the ability to tolerate three hours of therapy. Discharging the patient home is unsafe given the recent bilateral knee replacements and the established need for inpatient rehabilitation.

Formulating a hypothesis for this patient requires analyzing both systemic and local factors affecting wound healing. The low albumin level indicates malnutrition, which impairs healing, while the refusal to wear offloading footwear introduces continuous mechanical pressure to the plantar surface. Together, these cues perfectly support a hypothesis of impaired tissue integrity. Option A is incorrect because there are no specific cues indicating arterial disease, such as absent pulses or claudication. Option B is incorrect because while the patient is nonadherent with footwear, there is no data provided regarding their blood glucose trends or dietary adherence. Option D is incorrect because the patient is actively ambulating to the bathroom, and there are no cues suggesting that severe pain is limiting their physical mobility.

The correct answer is C. The teach-back method is the most effective way to assess health literacy and ensure the patient understands complex self-management instructions, such as adjusting medications based on weight. Nodding does not confirm comprehension. Option A is incorrect because patients often say they have no questions even when they do not understand the material. Option B is incorrect as written quizzes are inappropriate for assessing practical, daily clinical decision-making. Option D is incorrect because simply demonstrating how to use a scale does not confirm the patient knows what clinical actions to take based on the weight reading.

Recognizing cues in older adults requires understanding their atypical presentation of illness. The combination of new-onset confusion and tachypnea strongly suggests a systemic infection like pneumonia or a urinary tract infection, making option A the best choice. Option B treats the symptom without analyzing the underlying cause. Option C is inappropriate because acute confusion indicates a physiological issue, not a primary psychiatric disorder. Option D is less likely to be the primary cause without focal neurological deficits, whereas infection is a highly common trigger for acute delirium in this population.

Analyzing pain data requires the nurse to prioritize the patient's subjective self-report over objective behavioral cues. Patients often use distraction techniques, such as socializing, to cope with severe pain. Therefore, option B is correct. Option A inappropriately ignores the patient's reported pain level. Option C misinterprets a common coping mechanism as a psychological issue, which delays necessary pain management. Option D is unethical and outside the nurse's scope of practice, as it involves altering a prescribed dose based on a flawed analysis of behavioral cues.

The combination of a heart failure history, continuous IV fluids, and new crackles strongly points to fluid volume overload. The nurse must analyze these cues as a sign of impending hemodynamic compromise and decrease the fluid rate while notifying the provider, making option C correct. Option A is incorrect because the crackles are caused by fluid in the alveoli, not airway secretions. Option B treats bronchospasm, which does not address the underlying fluid excess. Option D would increase venous return to the heart, potentially worsening the pulmonary congestion.

Unrelieved pain out of proportion to the injury and sensory deficits like numbness are classic cues of compartment syndrome. The nurse must analyze this as a surgical emergency involving severe tissue ischemia and notify the team immediately (Option A). Option B is contraindicated because elevating the limb above the heart decreases arterial perfusion, worsening the ischemia. Option C is inappropriate as heat increases metabolic demand in already ischemic tissue. Option D ignores the critical underlying complication and merely masks the symptoms.

The combination of advanced kidney disease, muscle weakness, and peaked T waves are textbook cues for hyperkalemia. The nurse should analyze these findings by verifying the serum potassium level on the metabolic panel (Option B) before initiating treatment. Options A and D are highly dangerous, as adding potassium would worsen the potentially fatal cardiac dysrhythmia. Option C might eventually be part of the treatment plan, but verifying the laboratory data is the essential first step in analyzing the clinical picture before administering medications that alter electrolytes.

When dyspnea is driven by severe anxiety, adding a benzodiazepine like lorazepam breaks the panic cycle that exacerbates breathlessness. Another dose of morphine may not target the acute panic since one was recently given. High-flow oxygen and chest physiotherapy are overly burdensome and do not address the psychological component.

The correct answer is B because a death resulting from trauma, such as a motor vehicle collision, is a mandatory coroner's case. In these situations, the nurse must preserve the body as a potential crime scene or investigative subject, meaning all lines, tubes, and medical devices must remain entirely undisturbed. Option A is incorrect because removing intravenous lines destroys potential evidence and violates legal protocols for traumatic deaths. Option C is incorrect because extracting the endotracheal tube alters the airway status, which the medical examiner must assess during the autopsy. Option D is incorrect because disconnecting the urinary catheter also tampers with the body's state at the time of death. The nurse should secure the room and wait for the medical examiner to release the body.

Adults bring a wealth of life experience to their learning, and connecting new concepts to their existing knowledge base significantly enhances understanding and retention. Comparing fluid tracking to inventory management leverages the patient's specific professional background to make an abstract medical concept highly relatable. Explaining pathophysiology is often too theoretical and fails to utilize the patient's practical background. Providing a standardized video is a generic approach that misses the opportunity to individualize the teaching to the patient's unique history. Instructing the patient to strictly measure liquids is directive and lacks the conceptual bridge needed to help the adult learner internalize the behavior change.

By reflecting feelings, the nurse validates the patient's frustration, which is the first step in de-escalating anger and building trust. Option A is defensive and shifts focus to unit problems rather than the patient's experience. Option C makes unrealistic promises that the nurse may not be able to keep, potentially damaging trust further if another delay occurs. Option D encourages an adversarial environment and focuses on an investigation rather than addressing the patient's immediate emotional distress.

Patients with expressive aphasia understand language but struggle to produce it. Providing alternative communication tools like a visual scale and allowing adequate processing time empowers the patient to communicate their needs accurately. Option A is inappropriate because expressive aphasia is not a hearing deficit. Option B assumes the agitation is solely from pain without verifying the severity or location, bypassing the patient's autonomy. Option C offers false reassurance and ignores the immediate need to assess and treat the patient's current pain.

Asking the patient to describe their symptoms is an open-ended technique for exploring symptoms that uncovers the root cause of non-adherence (e.g., hypoglycemia) without judgment. Option A uses fear-based communication, which is non-therapeutic and rarely motivates long-term behavioral change. Option B uses "why," which often makes patients feel attacked and defensive. Option D uses authoritarian directives that ignore the patient's stated physical discomfort and fail to address the underlying reason for stopping the medication.

In a patriarchal cultural background, decision-making often involves the family leader. When the patient defers all medical questions to the son, the nurse should integrate the son into the education process to ensure compliance and respect cultural norms. Insisting the patient answer alone or asking the son to leave directly conflicts with their cultural support system, potentially damaging the therapeutic relationship. Documenting that the patient cannot participate is inaccurate, as the patient is participating through their preferred cultural framework.

When a patient with end-stage heart failure clearly expresses a desire for comfort care, the nurse's primary role is to advocate for those wishes. Facilitating a family meeting is the best approach because it provides a structured environment to discuss the patient's preferences and address the family's concerns. This aligns interventions with the patient's values while managing complex family dynamics. Option B is incorrect because a palliative consult should support the patient, not be used aggressively to override family members. Option C is inappropriate because it focuses on a medical intervention the patient has already rejected, ignoring their preference for comfort. Option D is premature and dismissive; simply discharging the patient without addressing the family conflict can lead to unsafe transitions and increased distress. Advocating for patient autonomy requires clear communication regarding goals of care.

The patient is experiencing acute respiratory distress, requiring immediate clinical intervention via the rapid response team. Simultaneously, the nurse must use the chain of command by notifying the charge nurse to escalate the communication failure. Option B delays necessary care for an unstable patient. Option C is outside the scope of practice without a specific order for this acute change. Option D skips essential steps in the chain of command, as the charge nurse or nursing supervisor should be the next contact before reaching executive leadership.

When a provider refuses to correct an unsafe order, the nurse must withhold the medication and escalate the issue through the nursing chain of command. The nursing supervisor will collaborate with medical leadership to resolve the conflict. Option A violates the nurse's duty to prevent harm by administering a dangerous dose. Option B is incomplete because simply withholding and documenting does not resolve the patient's need for appropriate anticoagulation. Option C incorrectly jumps to the medical director without first engaging the nursing supervisor to facilitate the interdisciplinary communication.

The first step in addressing an unsafe assignment is to communicate directly with the charge nurse to request an adjustment or additional resources. Option A constitutes patient abandonment and violates professional standards. Option B might be a later step depending on state regulations, but it is premature before attempting to resolve the issue with the immediate supervisor. Option D involves inappropriate delegation, as unlicensed assistive personnel cannot manage high-acuity telemetry monitoring or nursing assessments.

The patient's crossed arms and avoids eye contact contradict their verbal statement, indicating incongruence. The best response uses active listening by reflecting the non-verbal cues to explore underlying feelings. Option A directly addresses this non-verbal incongruence without being confrontational. Option B uses teach-back, which is a sound educational tool, but it ignores the immediate emotional and non-verbal cues. Option C relies on written clarity but dismisses the patient's current non-verbal communication entirely. Option D offers empathy but makes an assumption about the patient's feelings without validating the specific non-verbal behavior observed.

The patient with an exacerbation of chronic obstructive pulmonary disease who is pacing the room is expressing strong emotions and agitation. The most effective communication strategy is to use reflective listening by acknowledging the patient's feelings. Option C validates the patient's emotion without becoming defensive, which is foundational to therapeutic communication. Option A offers an excuse that shifts focus away from the patient's experience and breaches professional boundaries. Option B ignores the patient's emotional state entirely, focusing only on the task, which can escalate anger. Option D is defensive and invalidates the patient's feelings.

The patient with end-stage renal disease and peaked T waves on the electrocardiogram is exhibiting signs of severe, life-threatening hyperkalemia. Effective written handoff communication, particularly the Recommendation phase of SBAR communication, requires specific, actionable, and urgent clinical directives. Option D provides precise, actionable recommendations to address the immediate hyperkalemia risk. Options A, B, and C use vague language ("closely," "frequently," "routine") and fail to address the immediate, critical need associated with the electrocardiogram findings. Clear, specific written handoffs prevent dangerous delays in critical interventions during transitions of care.

The patient experiencing acute alcohol withdrawal who is pacing the hallway, clenching their fists is displaying non-verbal cues of severe agitation and potential aggression. The most appropriate response utilizes non-verbal de-escalation techniques. Option B uses a non-threatening, open posture that helps reduce tension and respects personal space. Option A uses a confrontational posture (arms crossed, standing directly in front) that can provoke violence. Option C involves unwanted physical touch, which can be misinterpreted as a threat by an agitated or hallucinating patient. Option D uses a loud, authoritative tone that escalates the situation rather than calming the patient.

The SBAR framework organizes communication into Situation, Background, Assessment, and Recommendation. The correct option represents the Recommendation because it asks the provider for specific, actionable orders to address the patient's deterioration. Reporting the chronic history represents the Background component. Stating the clinical conclusion of acute respiratory distress represents the Assessment component. Describing the immediate vital signs and the reason for the call represents the Situation component. Using this structured approach ensures the provider receives a concise summary and a clear request for intervention.