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 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?
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.
A patient is admitted with suspected sepsis. Which combination of findings meets the Sepsis-3 quick SOFA (qSOFA) criteria?
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.
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?
Answer: Trimethoprim-sulfamethoxazole (TMP-SMX)
TMP-SMX contains a sulfonamide component and is contraindicated in patients with sulfa allergies.
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?
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.
When using the CIWA-Ar scale to assess alcohol withdrawal, which symptom is included in the scoring?
Answer: Tremor, diaphoresis, and perceptual disturbances
CIWA-Ar assesses 10 withdrawal signs including tremor, diaphoresis, anxiety, agitation, nausea/vomiting, headache, and perceptual disturbances.
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?
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.
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?
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.