MSNCB Patient Assessment & Clinical Decision-Making 3 — Questions and Answers
Question 1: A patient 24 hours post-total hip replacement reports sudden onset of sharp chest pain and dyspnea. SpO2 drops from 97% to 89%. Which condition does the nurse MOST suspect?
- Pulmonary embolism (Correct answer)
- Pneumonia
- Atelectasis
- Acute heart failure
Correct answer: Pulmonary embolism
Sudden pleuritic chest pain, dyspnea, and hypoxia following orthopedic surgery are classic signs of pulmonary embolism due to DVT.
Question 2: When assessing a patient for dehydration, which clinical finding is MOST reliable in older adults?
- Skin turgor over the sternum or forehead (Correct answer)
- Dark yellow urine color alone
- Thirst sensation
- Skin turgor on the back of the hand
Correct answer: Skin turgor over the sternum or forehead
Skin turgor on the sternum or forehead is more reliable in older adults because peripheral skin loses elasticity with aging, making hand turgor unreliable.
Question 3: A nurse is caring for a patient with liver cirrhosis who becomes increasingly confused and drowsy. Which assessment finding would MOST support the development of hepatic encephalopathy?
- Asterixis (flapping tremor) on hand extension (Correct answer)
- Bilateral pitting edema in lower extremities
- Spider angiomata on the chest wall
- Caput medusae on the abdomen
Correct answer: Asterixis (flapping tremor) on hand extension
Asterixis is a hallmark sign of hepatic encephalopathy caused by impaired ammonia metabolism affecting the brain.
Question 4: A patient with type 2 diabetes has a fasting blood glucose of 48 mg/dL and is alert and oriented. What is the FIRST nursing intervention?
- Administer 15–20 g of fast-acting oral carbohydrate and recheck glucose in 15 minutes (Correct answer)
- Administer IV dextrose 50% immediately
- Give glucagon 1 mg intramuscularly
- Notify the physician and hold next insulin dose
Correct answer: Administer 15–20 g of fast-acting oral carbohydrate and recheck glucose in 15 minutes
The 15-15 rule applies to conscious patients with hypoglycemia: 15 g of fast-acting carbohydrate followed by glucose recheck in 15 minutes.
Question 5: Which assessment tool is most appropriate for evaluating pressure injury risk in a hospitalized medical-surgical patient?
- Braden Scale (Correct answer)
- Morse Fall Scale
- AUDIT-C
- Pittsburgh Sleep Quality Index
Correct answer: Braden Scale
The Braden Scale assesses six risk factors for pressure injury development and is the standard tool used in acute care settings.
Question 6: A patient receiving a blood transfusion develops flushing, urticaria, and reports itching 15 minutes into the infusion. BP is 126/78 mmHg, HR 88 bpm. What should the nurse do FIRST?
- Stop the transfusion and maintain IV access with normal saline (Correct answer)
- Slow the transfusion rate and administer diphenhydramine
- Administer epinephrine 0.3 mg IM immediately
- Complete the transfusion and document the reaction
Correct answer: Stop the transfusion and maintain IV access with normal saline
Any suspected transfusion reaction requires immediate cessation of the transfusion while keeping the IV line patent with normal saline.
Question 7: A nurse assesses a patient's wound and documents 'serosanguineous drainage.' Which description best defines this finding?
- Thin, pink-tinged drainage containing serum and small amounts of blood (Correct answer)
- Thick, cloudy yellow drainage indicating infection
- Bright red drainage signifying active arterial bleeding
- Clear, watery drainage consistent with normal wound healing
Correct answer: Thin, pink-tinged drainage containing serum and small amounts of blood
Serosanguineous drainage is a mixture of serous fluid and blood, appearing pink and thin, which is expected in early wound healing.
MSNCB Patient Assessment & Clinical Decision-Making 3
A patient 24 hours post-total hip replacement reports sudden onset of sharp chest pain and dyspnea.
SpO2 drops from 97% to 89%.
Which condition does the nurse MOST suspect?