MSNCB Patient Assessment & Clinical Decision-Making 5

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?

Accepted Answer

Peaked T-waves and widened QRS on ECG

Answer

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?

Accepted Answer

Altered mentation, RR ≥ 22/min, systolic BP ≤ 100 mmHg

Answer

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?

Accepted Answer

Trimethoprim-sulfamethoxazole (TMP-SMX)

Answer

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?

Accepted Answer

Peritonitis from bowel perforation

Answer

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?

Accepted Answer

Tremor, diaphoresis, and perceptual disturbances

Answer

CIWA-Ar assesses 10 withdrawal signs including tremor, diaphoresis, anxiety, agitation, nausea/vomiting, headache, and perceptual disturbances.

(MSNCB) Medical-Surgical Nursing Certification Board Practice Test

(MSNCB) Medical-Surgical Nursing Certification Board Practice Test

MSNCB Patient Assessment & Clinical Decision-Making 5