MSNCB Patient Assessment & Clinical Decision-Making 4 — Questions and Answers
Question 1: A patient's arterial blood gas results show: pH 7.28, PaCO2 52 mmHg, HCO3 24 mEq/L. How should the nurse interpret these findings?
- Respiratory acidosis, uncompensated (Correct answer)
- Metabolic acidosis, uncompensated
- Respiratory alkalosis, compensated
- Mixed respiratory and metabolic acidosis
Correct answer: Respiratory acidosis, uncompensated
A low pH with elevated PaCO2 and normal HCO3 indicates primary respiratory acidosis with no metabolic compensation yet.
Question 2: During a nursing assessment, a patient reports that their pain 'spreads to the left jaw and left arm.' The patient's chief complaint is indigestion. Which action is the HIGHEST priority?
- Obtain a 12-lead ECG and notify the physician immediately (Correct answer)
- Administer an antacid and reassess in 30 minutes
- Assess for Helicobacter pylori risk factors
- Document findings and continue the routine assessment
Correct answer: Obtain a 12-lead ECG and notify the physician immediately
Radiating pain to the jaw and left arm with epigastric discomfort are classic signs of myocardial infarction requiring urgent cardiac evaluation.
Question 3: A nurse is assessing a patient with suspected deep vein thrombosis (DVT) in the right leg. Which assessment finding most supports this diagnosis?
- Unilateral calf pain, warmth, and edema with a positive Homans' sign (Correct answer)
- Bilateral leg swelling with pitting edema and varicose veins
- Cool, pale right foot with diminished dorsal pedal pulse
- Right leg muscle cramps that occur at night and resolve with walking
Correct answer: Unilateral calf pain, warmth, and edema with a positive Homans' sign
Unilateral calf erythema, warmth, tenderness, and edema with a positive Homans' sign are classic DVT indicators, though Homans' sign alone is not definitive.
Question 4: A patient is ordered to receive 1,000 mL of 0.9% NaCl over 8 hours. The IV tubing drop factor is 15 gtt/mL. What is the correct flow rate in drops per minute?
- 31 gtt/min (Correct answer)
- 21 gtt/min
- 42 gtt/min
- 15 gtt/min
Correct answer: 31 gtt/min
Flow rate = (1000 mL × 15 gtt/mL) ÷ (8 hr × 60 min) = 15,000 ÷ 480 = 31.25, rounded to 31 gtt/min.
Question 5: A nurse is assessing mental status using the MMSE. A patient with a score of 18/30 would be classified as having:
- Mild cognitive impairment (Correct answer)
- Normal cognitive function
- Severe cognitive impairment
- Moderate-to-severe cognitive impairment
Correct answer: Mild cognitive impairment
MMSE scores of 18–23 indicate mild cognitive impairment; scores below 18 suggest moderate-to-severe impairment.
Question 6: A post-operative patient develops confusion, tachycardia (HR 126), fever (38.9°C), diaphoresis, and agitation 12 hours after emergency surgery. The patient has a history of alcohol dependence. The nurse should MOST suspect:
- Alcohol withdrawal delirium (delirium tremens) (Correct answer)
- Malignant hyperthermia
- Sepsis from a surgical site infection
- Thyroid storm
Correct answer: Alcohol withdrawal delirium (delirium tremens)
Delirium tremens typically peaks 24–72 hours after alcohol cessation; the surgical stress likely triggered early onset withdrawal syndrome.
Question 7: While assessing a patient post-thyroidectomy, the nurse notes carpopedal spasm when inflating the blood pressure cuff. This finding is known as:
- Trousseau's sign, indicating hypocalcemia (Correct answer)
- Chvostek's sign, indicating hypocalcemia
- Homans' sign, indicating thrombosis
- Kernig's sign, indicating meningeal irritation
Correct answer: Trousseau's sign, indicating hypocalcemia
Trousseau's sign is carpal spasm elicited by inflating a BP cuff above systolic pressure for 3 minutes, indicating hypocalcemia from parathyroid injury.
MSNCB Patient Assessment & Clinical Decision-Making 4
A patient's arterial blood gas results show: pH 7.28, PaCO2 52 mmHg, HCO3 24 mEq/L.
How should the nurse interpret these findings?