MSNCB Patient Assessment & Clinical Decision-Making 5 — Questions and Answers
Question 1: A patient with chronic kidney disease has a potassium level of 6.2 mEq/L. Which assessment finding is the MOST concerning complication of this lab value?
- Peaked T-waves and widened QRS on ECG (Correct answer)
- Muscle weakness and fatigue
- Nausea and abdominal cramping
- Numbness and tingling in the extremities
Correct answer: Peaked T-waves and widened QRS on ECG
Hyperkalemia causes life-threatening cardiac dysrhythmias; peaked T-waves and widened QRS indicate severe cardiac toxicity requiring urgent intervention.
Question 2: A patient is admitted with suspected sepsis. Which combination of findings meets the Sepsis-3 quick SOFA (qSOFA) criteria?
- Altered mentation, RR ≥ 22/min, systolic BP ≤ 100 mmHg (Correct answer)
- Temperature > 38.3°C, WBC > 12,000, HR > 90 bpm
- Lactate > 2 mmol/L, BP < 90/60, urine output < 0.5 mL/kg/hr
- Positive blood cultures, fever, and altered consciousness
Correct answer: Altered mentation, RR ≥ 22/min, systolic BP ≤ 100 mmHg
The qSOFA score uses altered mentation, respiratory rate ≥ 22/min, and systolic BP ≤ 100 mmHg—each scoring 1 point; a score ≥ 2 suggests sepsis.
Question 3: A nurse reviews the chart of a patient admitted for cellulitis of the right lower leg and notes a 'sulfa allergy' documented in the medical record. The nurse should clarify the allergy BEFORE administering which antibiotic?
- Trimethoprim-sulfamethoxazole (TMP-SMX) (Correct answer)
- Amoxicillin-clavulanate
- Clindamycin
- Cephalexin
Correct answer: Trimethoprim-sulfamethoxazole (TMP-SMX)
TMP-SMX contains a sulfonamide component and is contraindicated in patients with sulfa allergies.
Question 4: A nurse is caring for a patient 6 hours post-appendectomy who develops a rigid, board-like abdomen and reports pain rated 9/10. Temperature is 38.7°C. Which complication does the nurse MOST suspect?
- Peritonitis from bowel perforation (Correct answer)
- Paralytic ileus
- Wound dehiscence
- Anastomotic leak
Correct answer: Peritonitis from bowel perforation
A board-like rigid abdomen with fever and severe pain post-appendectomy suggests peritonitis, a surgical emergency requiring immediate physician notification.
Question 5: When using the CIWA-Ar scale to assess alcohol withdrawal, which symptom is included in the scoring?
- Tremor, diaphoresis, and perceptual disturbances (Correct answer)
- Tachypnea, chest pain, and diaphoresis
- Bradycardia, hypothermia, and lethargy
- Hypoglycemia, seizures, and urinary retention
Correct answer: Tremor, diaphoresis, and perceptual disturbances
CIWA-Ar assesses 10 withdrawal signs including tremor, diaphoresis, anxiety, agitation, nausea/vomiting, headache, and perceptual disturbances.
Question 6: A nurse is caring for a patient with heart failure who has gained 3 lbs in 24 hours and reports increased dyspnea on exertion. Lung auscultation reveals crackles bilaterally. What is the MOST appropriate nursing intervention?
- Notify the physician and anticipate orders for diuresis (Correct answer)
- Restrict oral fluids to 500 mL and recheck weight in 4 hours
- Elevate the head of the bed and apply supplemental oxygen only
- Administer PRN furosemide if available and reassess in 1 hour
Correct answer: Notify the physician and anticipate orders for diuresis
A rapid 3-lb weight gain with pulmonary crackles and dyspnea indicates acute fluid overload; the physician must be notified promptly to order diuretic therapy.
Question 7: A nurse is assessing a patient who reports 'the worst headache of my life' with sudden onset. The patient is alert and oriented with a stiff neck and photophobia. Which condition is MOST likely?
- Subarachnoid hemorrhage (Correct answer)
- Tension headache
- Hypertensive urgency
- Bacterial meningitis
Correct answer: Subarachnoid hemorrhage
A sudden, thunderclap 'worst headache of life' with nuchal rigidity and photophobia is the classic presentation of subarachnoid hemorrhage until proven otherwise.
MSNCB Patient Assessment & Clinical Decision-Making 5
A patient with chronic kidney disease has a potassium level of 6.2 mEq/L.
Which assessment finding is the MOST concerning complication of this lab value?