MSNCB Patient Assessment & Clinical Decision-Making 4

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?

Accepted Answer

Respiratory acidosis, uncompensated

Answer

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?

Accepted Answer

Obtain a 12-lead ECG and notify the physician immediately

Answer

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?

Accepted Answer

Unilateral calf pain, warmth, and edema with a positive Homans' sign

Answer

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?

Accepted Answer

31 gtt/min

Answer

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:

Accepted Answer

Mild cognitive impairment

Answer

MMSE scores of 18–23 indicate mild cognitive impairment; scores below 18 suggest moderate-to-severe impairment.

(MSNCB) Medical-Surgical Nursing Certification Board Practice Test

(MSNCB) Medical-Surgical Nursing Certification Board Practice Test

MSNCB Patient Assessment & Clinical Decision-Making 4