MSNCB Patient Assessment & Clinical Decision-Making 3

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?

Accepted Answer

Pulmonary embolism

Answer

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?

Accepted Answer

Skin turgor over the sternum or forehead

Answer

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?

Accepted Answer

Asterixis (flapping tremor) on hand extension

Answer

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?

Accepted Answer

Administer 15–20 g of fast-acting oral carbohydrate and recheck glucose in 15 minutes

Answer

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?

Accepted Answer

Braden Scale

Answer

The Braden Scale assesses six risk factors for pressure injury development and is the standard tool used in acute care settings.

(MSNCB) Medical-Surgical Nursing Certification Board Practice Test

(MSNCB) Medical-Surgical Nursing Certification Board Practice Test

MSNCB Patient Assessment & Clinical Decision-Making 3