Patient Assessment & Clinical Decision-Making Flashcards
7 cards from real MSNCB practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Patient Assessment & Clinical Decision-Making flashcards as text
A post-operative patient reports pain rated 8/10 and is restless. The nurse notes BP 158/94 mmHg, HR 102 bpm, RR 22/min, and SpO2 96%. Which action should the nurse prioritize FIRST?
Answer: Administer the prescribed PRN analgesic
Pain is the most likely cause of the elevated BP and tachycardia; treating it first addresses the underlying problem and may normalize the other vitals.
When performing a focused abdominal assessment, the nurse should perform the physical examination techniques in which order?
Answer: Inspection, auscultation, percussion, palpation
Auscultation precedes percussion and palpation in the abdomen to avoid altering bowel sounds; inspection always comes first.
A patient with COPD has an SpO2 of 88% on room air. The physician orders oxygen at 2 L/min via nasal cannula. Which clinical decision best supports this order?
Answer: COPD patients rely on hypoxic drive; excessive O2 may suppress respiratory effort
Chronic CO2 retainers with COPD may depend on hypoxic drive to breathe, so cautious low-flow oxygen is used to achieve SpO2 of 88–92%.
A nurse is reviewing a patient's medication administration record and notes that metformin 1,000 mg was due 2 hours ago but not given. The patient is scheduled for a CT scan with IV contrast today. What is the priority nursing action?
Answer: Hold metformin and notify the radiologist and ordering physician before the scan
Metformin must be held before and after IV contrast administration due to risk of contrast-induced nephropathy leading to lactic acidosis.
Which finding during a neurological assessment would require the most URGENT intervention?
Answer: Unequal pupils with one dilated and non-reactive
A unilateral fixed dilated pupil suggests uncal herniation or cranial nerve III compression—a neurological emergency requiring immediate intervention.
A nurse receives a SBAR handoff reporting that a patient is 'not looking right.' Which initial assessment step is most appropriate?
Answer: Perform a rapid head-to-toe assessment and check vital signs
Directly assessing the patient with a rapid clinical evaluation provides objective data to determine the urgency of the situation.
A patient's morning potassium level is 2.9 mEq/L. The patient is on digoxin 0.125 mg daily and furosemide 40 mg daily. Which nursing action is most critical?
Answer: Hold digoxin and notify the physician of the hypokalemia
Hypokalemia potentiates digoxin toxicity; holding digoxin and notifying the physician prevents potentially fatal dysrhythmias.