Facts checked against msncb.orgLast checked Nov 4, 2026
The blueprint sorts questions by what a med-surg nurse does, not by organ system, and it gives leadership, delegation and quality almost as much room as bedside care. Each domain below lists what it asks and where candidates lose points, with its weight and its share of the 125 scored questions.
MSNCB's current blueprint, in force since May 2023, sorts questions by what a med-surg nurse does. It has no cardiac, GI or respiratory percentage.
Two domains, Nursing Teamwork and Collaboration (21%) and Professional Concepts (15%), are about leading, delegating, communicating and improving care rather than about any disease. Bedside routine does not cover them, so plan study time by weight, not by comfort.
Old blueprints still online
Study plans that split the exam into cardiac, GI or respiratory percentages do not match the current blueprint, which has no body-system weights. No blueprint change announced as of November 4, 2026; the job analysis repeats at least every 5 years.
Patient/Care Management: 32%, 40 questions
What it asks: The largest domain covers safety (falls, skin, restraints, suicide risk), infection prevention, medication management including IV therapy, ports, central lines and epidurals, pain and non-drug comfort measures, care before and after procedures, moderate sedation and nutrition.
Where points go:
Labs before the dose. Low potassium raises the risk of digoxin toxicity, and a loop diuretic makes it worse; questions expect you to check the level and hold or clarify.
NPO and hypoglycemic. A patient who cannot swallow safely gets IV dextrose, not juice.
Suspected air embolism from a central line: clamp, turn the patient onto the left side with the head down, and call for help.
Moderate sedation: the nurse monitoring the patient has no other task during the procedure.
Nursing Teamwork and Collaboration: 21%, 26 questions
What it asks: Delegation and supervision, mentoring and precepting, professional development, leadership and change, shared governance, and disaster planning with the hospital incident command system.
Where points go:
Disaster roles: in a declared incident, the unit works inside the incident command structure; the usual reporting lines step aside.
Surge capacity: freeing beds starts with the most stable patients who can safely go home or move to a lower level of care.
Shared governance means staff nurses shape practice standards through councils; a manager asking the unit for opinions is not the same thing.
Elements of Interprofessional Care: 17%, 21 questions
What it asks: The nursing process and clinical judgment, interdisciplinary rounds and problem-solving, care coordination and transitions, readmission risk and social needs, documentation in the EHR and on paper during downtime, and technology on the unit.
Where points go:
Late entries carry a "late entry" label and the time they were actually written; nobody edits an earlier note to fit.
Downtime: when the EHR goes down, the unit switches to its paper procedure, and everything recorded on paper is entered once the system is back.
Referral questions: pick the discipline whose scope matches the problem rather than having the nurse cover it alone.
Holistic Patient Care: 15%, 19 questions
What it asks: Patient-centered care, complaints and service recovery, culture, language and implicit bias, teaching and health literacy, health promotion, and palliative and end-of-life care, including post-mortem care, organ donation and coroner reporting.
Where points go:
Interpreters: a qualified medical interpreter, not a family member, for consent and teaching, even when the family offers.
Organ donation: the hospital notifies its organ procurement organization about deaths and imminent deaths; the bedside nurse does not open the donation request alone.
Checking understanding: "Do you have any questions?" confirms nothing; asking the client to explain or show the step in their own words does.
Professional Concepts: 15%, 19 questions
What it asks: Communication (SBAR, hand-off, closed loop, verbal orders, de-escalation), critical thinking and time management, a healthy work environment, scope of practice, ethics and law, quality management and evidence-based practice.
Where points go:
Just culture: human error is consoled, at-risk behavior is coached, reckless behavior is disciplined. An answer that punishes a slip is wrong.
Telephone orders: the nurse writes the order down and reads it back to the prescriber before carrying it out.
Quality measures: falls with injury, pressure injuries and catheter infections are nursing-sensitive indicators; patient-experience scores belong to HCAHPS.
The handbook first
The CMSRN certification handbook prints the full blueprint with every topic under each domain, plus the board's list of recommended references. Check any review book against it: one that organizes by body system does not follow the current blueprint.
Sample questions by domain
15 questions on this page · 0 answeredYour score: 0 of 0 correct
1/15 · Care management · 32%
A nurse is caring for a client with a newly diagnosed sacral pressure injury who is confined to bed. Which intervention is the priority to prevent further breakdown?
Use Check on the answer you favor. The verdict shows up with a short note on each choice.
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Topical antibiotics treat local infection, not pressure; routine use on an uninfected injury adds resistance risk and does nothing to offload the area.
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Pressure caused the injury, so scheduled turning that keeps weight off the sacrum protects the wound bed and the surrounding skin.
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Covering the wound is fine, but postponing inspection hides signs that the injury is deepening or becoming infected.
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Leaving the client in one position to spare the dressing keeps weight on the sacrum, which is exactly what makes the injury worse.
2/15 · Care management · 32%
A client with a stage 4 sacral pressure injury weighs 154 lb and needs 1.5 g of protein per kilogram daily. The enteral formula provides 60 g of protein per 1000 mL. How many mL of formula per day meet the protein requirement?
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571 mL comes from dividing 60 by 105 instead of 105 by 60, which inverts the protein-to-formula ratio.
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1167 mL is the volume for 70 g of protein: it treats the weight in kilograms as grams of protein and leaves out the 1.5 g/kg factor.
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3850 mL multiplies 1.5 g by 154 pounds instead of 70 kilograms, so the protein need and the volume are more than doubled.
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154 lb ÷ 2.2 = 70 kg; 70 kg × 1.5 g/kg = 105 g of protein; 105 g ÷ 60 g per 1000 mL × 1000 = 1750 mL a day.
3/15 · Care management · 32%
A client who used IV morphine PCA is being discharged on oral morphine with a planned dose reduction. Which nursing action is most appropriate before discharge?
Check
Verifying the IV-to-oral conversion, the taper steps, and the monitoring plan for pain and sedation catches dosing errors before the client goes home.
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Changing the route without reassessing pain and sedation removes the baseline needed to judge whether the oral dose is too high or too low.
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Encouraging self-escalation of an opioid at home invites oversedation and works against the planned dose reduction.
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Skipping the taper ignores the prescribed plan to reduce the dose, which prolongs opioid exposure and raises the risk of dependence.
4/15 · Teamwork · 21%
An RN is working with a UAP during a staffing shortage. Which task is appropriate for the RN to delegate to the UAP?
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A nicotine patch is a medication, and giving medications is outside the UAP role even when the client is stable.
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Inspecting a new admission's skin for breakdown is part of the initial assessment, which stays with the RN.
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On the first day of a texture change the client's swallow tolerance is unknown, so a licensed nurse watches for aspiration before feeding is handed off.
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Measuring and recording intake and output is standardized data collection a UAP is trained for; the RN interprets the totals for fluid balance.
5/15 · Teamwork · 21%
A client receiving comfort care has dysphagia, and the plan states 'mouth care only, nothing by mouth.' The nurse sees a UAP helping the client drink water. Which action should the nurse take first?
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An incident report documents what happened, but filling it out first leaves the client unassessed while aspiration develops.
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Calling the charge nurse is follow-up; it neither stops the drinking nor checks the client's breathing at this moment.
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Water given to a client with dysphagia can be aspirated, so the nurse halts it at once and checks airway and breathing before anything else.
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Waiting until the task is finished lets the client keep drinking; reviewing the care plan with the UAP belongs after the client is safe.
6/15 · Interprofessional · 17%
A nurse is coordinating discharge for a client with complex needs. Which action should the nurse prioritize?
Check
Follow-up visits are one piece of the plan; equipment, teaching, and services can still be missing once the calendar is full.
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Complex needs span several disciplines, so a single plan that combines their input covers the whole transition and avoids conflicting instructions.
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Completing the nursing notes covers only the nurse's own part; coordinating discharge means making sure the other pieces are in place too.
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Medication reconciliation is essential but covers only drugs, leaving the client's other needs unaddressed.
7/15 · Holistic care · 15%
A client with a new below-knee amputation tells the nurse that the most important goal is to walk into a grandchild's wedding in 4 weeks. How should the nurse use this information when updating the care plan?
Check
Typical rehabilitation timelines describe the average client and leave out the goal this client just said matters most.
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An unchanged standard plan ignores the client's stated priority, which is the core of patient-centered planning.
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Building the targets with physical therapy around the client's own deadline turns a personal priority into measurable, motivating steps.
Check
Withholding goals until the client 'accepts limits' is paternalistic and throws away a strong source of motivation.
8/15 · Holistic care · 15%
A client with low health literacy is discharged on seven new medications. The nurse can emphasize only one item on the front page of the medication handout. Which content should the nurse place there?
Check
Warning signs that call for help right away are what most directly prevent serious harm at home, so they belong in the one place the client is sure to see.
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Food and drink interactions matter for some drugs, but a long list on the front page buries the most urgent message.
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Refill dates and the pharmacy number keep the supply going, yet a missed warning sign causes harm faster than a late refill, so they go inside.
Check
Purposes and side effects of seven drugs crowd the front page for a reader with low literacy; that teaching fits the inner pages and teach-back.
9/15 · Professional · 15%
A client with advanced dementia has an advance directive declining CPR, and a DNR order is in the chart. The client's daughter, the health care agent, tells the nurse, 'I want everything done for Mom.' Which action should the nurse take?
Check
An agent must decide as the client would have, and the directive records that choice; a family meeting with the provider helps the daughter understand it and grieve.
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No override form lets an agent cancel the client's own written refusal of CPR, so asking for a signature creates false authority.
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Being the agent obliges the daughter to follow the client's known wishes, not to replace them with her own, so a switch to full code is wrong.
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Ethics review is for genuine uncertainty; a clear directive backed by a valid order is not put on hold while a committee meets.
10/15 · Professional · 15%
After a family meeting, a patient with decision-making capacity chooses DNR status. The provider agrees but says the order will be written tomorrow. Which action should the nurse take?
Check
A note documenting the meeting is not an order; withholding resuscitation on it alone leaves the nurse without legal authority.
Check
Until the provider enters the order the patient is full code, so an arrest tonight would bring the resuscitation the patient declined; the order has to be written now.
Check
A DNR wristband signals an order that does not exist yet, which confuses responders and carries no legal force.
Check
Telling oncoming staff by word of mouth is unreliable across shifts and cannot authorize withholding CPR.
11/15 · Teamwork · 21%
Two staff nurses begin arguing loudly at the nurses' station about an unfair assignment, and clients' family members are nearby. Which action should the charge nurse take FIRST?
Check
Taking the argument out of public view shields clients and families from the disruption and gives the charge nurse a setting to help the nurses resolve it.
Check
Reassigning one nurse's clients ends the shouting for now but sidesteps the conflict and can look like a reward for the outburst.
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Sending the nurses to the manager before addressing the conflict on the unit skips the charge nurse's own role in resolving it.
Check
Leaving the argument until the end of the shift keeps it in front of families and lets the tension affect care for hours.
12/15 · Interprofessional · 17%
A root cause analysis reviews a missed deterioration: over one hour the client generated a low-battery warning, a routine medication reminder, an SpO2 artifact alarm, and finally a sustained tachycardia alarm that the nurse acknowledged but dismissed. What is the most likely systemic root cause?
Check
Nothing in the timeline points to staffing; the nurse was present and acknowledged the alarm, so the failure lies in how signals were handled.
Check
Any nurse knows sustained tachycardia is abnormal; a gap in vital-sign education does not explain why a recognized alarm was dismissed.
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The tachycardia alarm reflected a real change in the client, so faulty telemetry equipment was not the cause, even if the SpO2 artifact was noise.
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A run of low-value alerts trains staff to tune signals out, so the one critical alarm gets dismissed; that is a system design problem, not an individual lapse.
13/15 · Interprofessional · 17%
A nurse writes the functional-status line of a home-health referral. Which description provides adequate detail for triage acceptance?
Check
Motivation and family support matter for the plan, but they describe the client's resources, not what the client can physically do.
Check
Living alone in a home with stairs is environmental information; it belongs in the referral but does not state the client's functional level.
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Requiring 'some help' is too vague to staff a case; the agency cannot tell whether that means standby help or full physical assistance.
Check
A specific assistance level for named activities tells the agency how much hands-on help the client needs, so it can accept the case and staff it correctly.
14/15 · Professional · 15%
A provider orders an insulin dose four times the client's usual dose. The nurse raises the concern, and the provider dismisses it. Which action should the nurse take next?
Check
Charting the concern documents the disagreement, but the nurse who then gives an unsafe ordered dose is still accountable for the harm.
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Giving half the dose means giving an amount no one ordered; the nurse cannot rewrite an order to split the difference.
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A fourfold insulin dose can cause severe hypoglycemia, so the nurse holds it and takes the concern up the chain of command, such as the charge nurse or supervisor, until it is resolved.
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Checking the glucose every hour after a fourfold dose only detects the hypoglycemia; it does not prevent it.
15/15 · Holistic care · 15%
A client tells the nurse that a call light went unanswered for 20 minutes during the night. Which response reflects service recovery?
Check
Explaining that the night shift was short-staffed sounds like an excuse and leaves the complaint and the need unaddressed.
Check
The patient relations office handles formal grievances, but referring the client there first skips the response the nurse can give at the bedside.
Check
Service recovery means owning the lapse: an apology, meeting the client's need at once, and following up so the delay is explained and prevented.
Check
Noting the complaint and waiting for a formal grievance lets a fixable problem grow; service recovery happens when the complaint is voiced.
The free one that matters is the board's certification handbook, which contains the blueprint. PDF copies of commercial review books posted on file sites may be old editions; check the edition date.
Where should CMSRN prep start?
With the domain your practice score shows is weakest. By weight, the largest is Patient/Care Management (32%).
Does the exam test pharmacology?
Yes, inside Patient/Care Management: safe administration, interactions, IV therapy and patient teaching about medicines. There is no separate pharmacology domain.