MSNCB Patient Assessment & Clinical Decision-Making 2

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?

Accepted Answer

Administer the prescribed PRN analgesic

Answer

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?

Accepted Answer

Inspection, auscultation, percussion, palpation

Answer

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?

Accepted Answer

COPD patients rely on hypoxic drive; excessive O2 may suppress respiratory effort

Answer

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?

Accepted Answer

Hold metformin and notify the radiologist and ordering physician before the scan

Answer

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?

Accepted Answer

Unequal pupils with one dilated and non-reactive

Answer

A unilateral fixed dilated pupil suggests uncal herniation or cranial nerve III compression—a neurological emergency requiring immediate intervention.

(MSNCB) Medical-Surgical Nursing Certification Board Practice Test

(MSNCB) Medical-Surgical Nursing Certification Board Practice Test

MSNCB Patient Assessment & Clinical Decision-Making 2