What this section covers: Recognize cues, Analyze cues, Prioritize hypotheses, Generate solutions, Take action, Evaluate outcomes, 3 case studies of 6 items on every exam (18 items), plus about 10% stand-alone clinical judgment items.
12 free practice questions
Click an answer: you see at once whether it is right, with the explanation.
Read the passage: Older adult with pneumonia and new confusion
Client: 81-year-old woman admitted to the medical unit yesterday with right lower lobe community-acquired pneumonia. History: type 2 diabetes, hypertension, osteoarthritis. Lives alone; normally fully oriented and independent. Medications: metformin, lisinopril; oral antibiotic started yesterday evening.
Nursing notes
Day 2, 0700: Alert and oriented x4. Productive cough with yellow sputum. Crackles in the right lung base. Drank 300 mL overnight. T 99.5°F (37.5°C), HR 92/min, RR 20/min, BP 134/78 mm Hg, SpO2 94% on oxygen 2 L/min by nasal cannula.
Day 2, 1100: Her daughter says her mother "is not making sense" and keeps asking where she is. Oriented to person only. Skin warm and flushed. Has not voided since 0600. T 102.4°F (39.1°C), HR 118/min, RR 28/min, BP 94/56 mm Hg (mean arterial pressure 69 mm Hg), SpO2 91% on oxygen 2 L/min.
Laboratory results (drawn at 1100)
White blood cells 17,800/mm³ (reference 4,500-11,000/mm³)
Lactate 3.1 mmol/L (reference less than 2 mmol/L)
Blood glucose 212 mg/dL
Creatinine 1.6 mg/dL (on admission 0.9 mg/dL)
Question 1The nurse compares the 1100 findings with the 0700 findings. Which finding is the most important new cue that needs follow-up?
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Answer: B — Disorientation to place and time.
The crackles, the yellow sputum and the oxygen were already present at 0700 and fit the known pneumonia. The acute change in mental status is new: in older adults, a change in mental status is often one of the first signs of sepsis, and any older adult with such a change should be screened for sepsis.
Checked against: OpenStax Medical-Surgical Nursing, 23.3 Septic Shock (Life-Stage Context: Older Adults and Sepsis)
Same passage as above.
Question 2The nurse applies the quick SOFA (qSOFA) screen to the 1100 data. How many qSOFA criteria does the client meet?
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Answer: D — 3.
qSOFA gives one point each for a systolic blood pressure of 100 mm Hg or less (94), altered mental status (oriented to person only) and a respiratory rate of 22/min or more (28), so all three are met. A score of 2 or more flags a higher risk of a poor outcome; the Surviving Sepsis Campaign 2021 advises against using qSOFA alone as a screening tool, so it never replaces the full assessment.
Checked against: OpenStax Medical-Surgical Nursing, 23.3 Septic Shock (Assessments and Diagnostics: qSOFA); thresholds per Sepsis-3 (Singer et al., JAMA 2016) and Surviving Sepsis Campaign 2021 screening recommendation
Same passage as above.
Question 3Which condition is the client most likely developing?
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Answer: C — Sepsis with signs of poor tissue perfusion from the lung infection.
Fever, tachycardia, fast breathing, low blood pressure, a high white cell count, no urine for 5 hours, a rising creatinine and a lactate above 2 mmol/L point to sepsis with hypoperfusion. Dementia does not fit an abrupt change from full orientation 4 hours earlier, and a glucose of 212 mg/dL rules out hypoglycemia.
Checked against: OpenStax Medical-Surgical Nursing, 23.3 Septic Shock (Diagnostics and Laboratory Values; Recognizing Cues and Analyzing Cues)
Same passage as above.
Question 4The provider prescribes blood cultures x2, a broad-spectrum IV antibiotic, an IV fluid bolus and a repeat lactate. How should the nurse plan the cultures and the antibiotic?
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Answer: A — Draw the blood cultures first, then start the IV antibiotic without delay.
Cultures are obtained before broad-spectrum antibiotics so the organism can still be identified, and the first antibiotic dose must then be given promptly because delay worsens the prognosis. Culture results take 1 to 3 days, so waiting for them would dangerously delay treatment.
Checked against: OpenStax Medical-Surgical Nursing, 23.3 Septic Shock (Diagnostics; Prioritizing Hypotheses, Generating Solutions, and Taking Action)
Same passage as above.
Question 5While the IV fluid bolus is infusing, which action is most important for the nurse to take?
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Answer: D — Auscultate the lungs and watch for increasing shortness of breath.
Large-volume fluid resuscitation is needed to restore perfusion, but the nurse must assess for its complications, such as pulmonary edema, especially in a client who already has pneumonia. Changing the prescribed rate on one's own or waiting for urine would delay the treatment of hypoperfusion, and a confused client should not be pushed to drink large volumes.
Checked against: OpenStax Medical-Surgical Nursing, 23.3 Septic Shock (Prioritizing Hypotheses, Generating Solutions, and Taking Action)
Same passage as above.
Question 6Three hours later, which set of findings best shows that treatment is working?
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Answer: B — MAP 72 mm Hg, urine output 45 mL/hour, lactate 1.6 mmol/L, oriented x3.
A mean arterial pressure at or above the 65 mm Hg target, urine output of at least 30 mL/hour and a lactate under 2 mmol/L indicate adequate perfusion, and the return to her usual orientation confirms better brain perfusion. A lower temperature alone does not show that perfusion has improved.
Checked against: OpenStax Medical-Surgical Nursing, 23.3 Septic Shock (Recognizing Cues and Analyzing Cues: MAP, urine output, lactate)
Read the passage: Headache and swelling at 35 weeks
Client: 24-year-old, gravida 1 para 0, at 35 weeks' gestation, sent from the prenatal clinic to labor and delivery. No chronic conditions. Blood pressure at 28 weeks: 112/70 mm Hg.
1400 admission assessment: Reports a headache since this morning that acetaminophen did not relieve, "spots" in her vision, and pain in the upper abdomen under the ribs. Face and hands swollen; her rings no longer fit. Deep tendon reflexes 3+ with 2 beats of ankle clonus. Fetal heart rate baseline 140/min.
Vital signs: BP 164/108 mm Hg; repeated 15 minutes later 162/110 mm Hg. HR 88/min, RR 18/min, SpO2 98% on room air.
Laboratory results: urine protein 3+ (dipstick); platelets 168,000/mm³ (reference 150,000-450,000/mm³); AST 38 units/L (reference 10-40 units/L).
Provider's assessment: preeclampsia with severe features.
Orders: magnesium sulfate IV loading dose, then continuous infusion by pump; labetalol IV per protocol; indwelling urinary catheter with strict intake and output; continuous electronic fetal monitoring; seizure precautions.
Question 7Which assessment finding is the most important warning sign that the client may have a seizure?
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Answer: A — Deep tendon reflexes 3+ with ankle clonus.
Hyperreflexia and clonus are warning signs of seizure risk in preeclampsia. Edema is common and does not signal an imminent seizure, the fetal heart rate baseline is not a maternal seizure cue, and the platelet count is within the reference range.
Checked against: OpenStax Maternal-Newborn Nursing, 12.2 Conditions Limited to Pregnancy (Preeclampsia)
Same passage as above.
Question 8Which group of findings best supports preeclampsia rather than high blood pressure alone?
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Answer: C — New hypertension after 20 weeks with 3+ proteinuria, headache and visual spots.
Preeclampsia is a multisystem disorder after 20 weeks: besides high blood pressure, its signs include proteinuria, edema, headache, vision changes and epigastric pain. Elevated readings alone define hypertension, not organ involvement, and normal platelets and AST argue against HELLP syndrome rather than for preeclampsia.
Checked against: OpenStax Maternal-Newborn Nursing, 12.2 Conditions Limited to Pregnancy (Hypertensive Disorders; Preeclampsia)
Same passage as above.
Question 9Before treatment starts, the client is at highest risk for which complication?
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Answer: B — Eclampsia (seizures).
Untreated preeclampsia can progress to seizures, and this client has hyperreflexia with clonus. HELLP syndrome is diagnosed from low platelets and liver involvement, but her platelets and AST are normal; she has not given birth, and magnesium has not been started yet.
Checked against: OpenStax Maternal-Newborn Nursing, 12.2 Conditions Limited to Pregnancy (Preeclampsia; Eclampsia)
Same passage as above.
Question 10Which medication should the nurse make sure is immediately available at the bedside once the magnesium sulfate infusion begins?
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Answer: A — Calcium gluconate.
Calcium gluconate, usually kept at the bedside, is the antidote given as ordered for magnesium toxicity; the drug label also states that IV calcium antagonizes the effects of magnesium. Naloxone reverses opioids, protamine reverses heparin and vitamin K reverses warfarin.
Checked against: OpenStax Maternal-Newborn Nursing, 12.2 Conditions Limited to Pregnancy (QSEN: Safe Administration and Monitoring of Magnesium Sulfate during Pregnancy)
Same passage as above.
Question 11Six hours into the magnesium infusion, the client is drowsy, her respiratory rate is 10/min, patellar reflexes are absent and urine output has been 60 mL over the past 4 hours. What should the nurse do first?
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Answer: D — Stop the magnesium sulfate infusion.
Absent patellar reflexes, slow breathing and low urine output are signs of magnesium toxicity. The nurse stops the infusion immediately, notifies the provider, draws a magnesium level and has calcium gluconate ready. Continuing or increasing the infusion would worsen the toxicity, and labetalol does not treat it.
Checked against: OpenStax Maternal-Newborn Nursing, 12.2 Conditions Limited to Pregnancy (QSEN: Safe Administration and Monitoring of Magnesium Sulfate)
Same passage as above.
Question 12After the toxicity is treated, the provider resumes the infusion at a lower rate. Which findings 2 hours later show the infusion can safely continue?
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Answer: C — Patellar reflexes present, respiratory rate 16/min, urine output 120 mL over the last 4 hours.
The magnesium sulfate label lists the signs of a safe regimen: a patellar reflex is present, there is no respiratory depression (about 16 breaths or more a minute), and urine output is 100 mL or more in the 4 hours before each dose because magnesium leaves the body only through the kidneys. Each other option misses one of the three conditions.
Checked against: DailyMed, Magnesium Sulfate Injection USP label, Precautions and Overdosage
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