MSNCB Patient Assessment & Clinical Decision-Making 2 — Questions and Answers
Question 1: A post-operative patient reports pain rated 8/10 and is restless. The nurse notes BP 158/94 mmHg, HR 102 bpm, RR 22/min, and SpO2 96%. Which action should the nurse prioritize FIRST?
- Administer the prescribed PRN analgesic (Correct answer)
- Notify the physician of elevated blood pressure
- Reposition the patient for comfort
- Apply supplemental oxygen via nasal cannula
Correct answer: Administer the prescribed PRN analgesic
Pain is the most likely cause of the elevated BP and tachycardia; treating it first addresses the underlying problem and may normalize the other vitals.
Question 2: When performing a focused abdominal assessment, the nurse should perform the physical examination techniques in which order?
- Inspection, auscultation, percussion, palpation (Correct answer)
- Inspection, percussion, auscultation, palpation
- Auscultation, inspection, percussion, palpation
- Palpation, auscultation, inspection, percussion
Correct answer: Inspection, auscultation, percussion, palpation
Auscultation precedes percussion and palpation in the abdomen to avoid altering bowel sounds; inspection always comes first.
Question 3: A patient with COPD has an SpO2 of 88% on room air. The physician orders oxygen at 2 L/min via nasal cannula. Which clinical decision best supports this order?
- COPD patients rely on hypoxic drive; excessive O2 may suppress respiratory effort (Correct answer)
- Nasal cannula delivers precise FiO2, eliminating CO2 retention risk
- All COPD patients require low-flow oxygen to prevent pulmonary hypertension
- An SpO2 of 88% does not require oxygen intervention
Correct answer: COPD patients rely on hypoxic drive; excessive O2 may suppress respiratory effort
Chronic CO2 retainers with COPD may depend on hypoxic drive to breathe, so cautious low-flow oxygen is used to achieve SpO2 of 88–92%.
Question 4: A nurse is reviewing a patient's medication administration record and notes that metformin 1,000 mg was due 2 hours ago but not given. The patient is scheduled for a CT scan with IV contrast today. What is the priority nursing action?
- Hold metformin and notify the radiologist and ordering physician before the scan (Correct answer)
- Administer the missed dose immediately before the scan
- Proceed with the scan and administer metformin after
- Document the missed dose and reschedule the scan
Correct answer: Hold metformin and notify the radiologist and ordering physician before the scan
Metformin must be held before and after IV contrast administration due to risk of contrast-induced nephropathy leading to lactic acidosis.
Question 5: Which finding during a neurological assessment would require the most URGENT intervention?
- Unequal pupils with one dilated and non-reactive (Correct answer)
- Mild hand tremors bilaterally
- Score of 14 on the Glasgow Coma Scale
- Deep tendon reflexes graded 2+ bilaterally
Correct answer: Unequal pupils with one dilated and non-reactive
A unilateral fixed dilated pupil suggests uncal herniation or cranial nerve III compression—a neurological emergency requiring immediate intervention.
Question 6: A nurse receives a SBAR handoff reporting that a patient is 'not looking right.' Which initial assessment step is most appropriate?
- Perform a rapid head-to-toe assessment and check vital signs (Correct answer)
- Call the rapid response team immediately
- Review the chart for recent laboratory values
- Ask the outgoing nurse to clarify what 'not looking right' means before accepting report
Correct answer: Perform a rapid head-to-toe assessment and check vital signs
Directly assessing the patient with a rapid clinical evaluation provides objective data to determine the urgency of the situation.
Question 7: A patient's morning potassium level is 2.9 mEq/L. The patient is on digoxin 0.125 mg daily and furosemide 40 mg daily. Which nursing action is most critical?
- Hold digoxin and notify the physician of the hypokalemia (Correct answer)
- Administer both medications as scheduled and recheck potassium in 4 hours
- Hold furosemide only and administer oral potassium supplement
- Administer digoxin and request a repeat potassium level before furosemide
Correct answer: Hold digoxin and notify the physician of the hypokalemia
Hypokalemia potentiates digoxin toxicity; holding digoxin and notifying the physician prevents potentially fatal dysrhythmias.
MSNCB Patient Assessment & Clinical Decision-Making 2
A post-operative patient reports pain rated 8/10 and is restless.
The nurse notes BP 158/94 mmHg, HR 102 bpm, RR 22/min, and SpO2 96%.
Which action should the nurse prioritize FIRST?