Gastrointestinal bleeding and hepatic disorders are high-acuity med-surg topics the CMSRN tests. Practice the GI-bleed, ulcer, and cirrhosis scenarios below, each with a full rationale.
Question 1
During unit rounds, a nurse caring for a patient with advanced cirrhosis and GI bleeding expresses concern about rising ammonia levels. The gastroenterologist orders lactulose, but the patient refuses due to diarrhea. Which interdisciplinary approach is most appropriate?
- A) A) Document refusal and notify the provider to explore alternatives later.
- B) B) Have the pharmacist suggest alternative medications during rounds.✓
- C) C) Delegate the dietician to educate the patient about lactulose importance.
- D) D) Ask the case manager to arrange hospice evaluation given treatment nonadherence.
Show rationale
Option B leverages real-time team expertise (pharmacist) to address medication refusal, aligning with rounding goals of immediate problem-solving. It considers cirrhosis complications and patient autonomy. Option A delays intervention for escalating ammonia. Option C uses the wrong team member; dietitians address nutrition, not medication. Option D inappropriately escalates to hospice without exhausting alternatives. Guidelines stress resolving treatment barriers collaboratively during rounds to prevent adverse events.
Question 2
A patient receiving morphine for pancreatitis develops sudden facial flushing and urticaria without dyspnea. Allergy history includes anaphylaxis to codeine. Which action is indicated?
- A) A) Stop morphine infusion and administer diphenhydramine 50 mg IV✓
- B) B) Continue morphine but reduce dose and monitor for anaphylaxis
- C) C) Switch to fentanyl and observe for cross-reactivity
- D) D) Discontinue morphine and give methylprednisolone 40 mg IV
Show rationale
Pruritus without respiratory symptoms indicates histamine release, not true allergy. Diphenhydramine is first-line for opioid-induced pruritus (ASPMN). Codeine anaphylaxis (IgE-mediated) differs from morphine’s direct mast cell effect, so cross-reactivity (C) is unlikely. Continuing morphine (B) exacerbates symptoms. Steroids (D) are for anaphylaxis, not isolated pruritus. Flushing/urticaria cue histamine response requiring H1 blockade.
Question 3
A patient with cirrhosis develops asterixis and lethargy. Ammonia level is 120 μmol/L, and the nurse observes undigested orange peels in the emesis basin. Which intervention demonstrates appropriate clinical judgment?
- A) A) Administer lactulose immediately to reduce ammonia absorption✓
- B) B) Offer high-protein supplement to correct malnutrition
- C) C) Position supine to minimize aspiration risk
- D) D) Restrict visitors to reduce sensory stimulation
Show rationale
Elevated ammonia + asterixis/lethargy indicate hepatic encephalopathy. Undigested peels suggest dietary indiscretion worsening hyperammonemia. Lactulose traps ammonia in the colon per AASLD guidelines. Protein restriction (B) is needed long-term but doesn't address acute crisis. Semi-Fowler's positioning (C) reduces aspiration; supine increases risk. Sensory reduction (D) is less urgent than toxin clearance.
Question 4
A cirrhotic patient with ascites develops agitation and asterixis after aggressive paracentesis. Serum sodium is 128 mEq/L, potassium 3.0 mEq/L, and ammonia 120 µmol/L. Which management aligns with current evidence?
- A) A) Restrict protein to 40 g/day and start lactulose
- B) B) Administer 3% saline and potassium supplements
- C) C) Infuse albumin and correct potassium deficit✓
- D) D) Initiate broad-spectrum antibiotics immediately
Show rationale
Hyponatremia and hypokalemia here are secondary to post-paracentesis circulatory dysfunction and diuretic use, exacerbating hepatic encephalopathy. Albumin prevents intravascular depletion, and potassium correction (C) addresses alkalosis that worsens ammonia toxicity. Protein restriction/lactulose (A) is outdated for acute encephalopathy. Hypertonic saline (B) risks volume overload in cirrhosis. Antibiotics (D) are for confirmed infection. Cues (post-paracentesis, asterixis, electrolyte imbalances) prioritize volume/potassium correction per AASLD guidelines.
Question 5
A unit with 90% occupancy has one open bed. The ED requests admission for either an 80-year-old with UTI and delirium or a 45-year-old with pancreatitis and severe pain. Staffing permits only one admission without overtime. Which factor is most critical in allocation?
- A) A) The delirium patient's risk for falls without 1:1 observation.✓
- B) B) The pancreatitis patient's need for frequent IV narcotic administration.
- C) C) The delirium patient's potential for rapid deterioration if untreated.
- D) D) The pancreatitis patient's longer projected length of stay.
Show rationale
Option A reflects immediate safety risk; delirium increases falls/injury in unfamiliar environments, requiring closer monitoring than pain management. Option B's narcotic needs are manageable with standard checks. Option C is mitigated by antibiotics starting in ED. Option D is less urgent than acute safety threats. AMSN triage principles prioritize preventing harm when resources are limited; delirium poses higher immediate risk than controlled pain.
Question 6
During discharge reconciliation, a nurse discovers a hospitalized patient with rheumatoid arthritis was prescribed celecoxib 200mg BID despite their chart documenting aspirin 81mg daily for coronary artery disease. The patient reports taking both at home. Which action best addresses the reconciliation discrepancy?
- A) A) Documenting both medications as reconciled home regimen
- B) B) Consulting pharmacy about potential NSAID interactions
- C) C) Contacting the prescriber for therapeutic alternatives✓
- D) D) Educating the patient to separate administration times
Show rationale
Concurrent NSAIDs (celecoxib) and antiplatelets (aspirin) increase GI bleeding risk per American College of Rheumatology guidelines. Option A ignores the hazardous interaction. Option B delays resolution as pharmacists cannot independently discontinue medications. Option D is ineffective since timing doesn't mitigate interaction risks. Only option C addresses the core safety issue by facilitating substitution (e.g., acetaminophen) or gastroprotection, aligning with Joint Commission medication reconciliation standards.
Question 7
A patient with cirrhosis (Child-Pugh B) receives moderate sedation for paracentesis. After 50mcg fentanyl, respirations become shallow at 8/min with SpO2 92%. Which response prioritizes metabolic risk factors?
- A) A) Stimulate patient and withhold further opioids
- B) B) Administer naloxone 0.1mg IV every 2 minutes✓
- C) C) Intubate for airway protection immediately
- D) D) Obtain ABG to assess acid-base status
Show rationale
Cirrhosis impairs opioid metabolism, causing rapid respiratory depression. Titrated naloxone reverses toxicity while avoiding abrupt withdrawal, per AANA guidelines. Stimulation (A) is insufficient for significant depression. Intubation (C) is excessive for responsive hypoxia. ABGs (D) delay treatment; capnography/SpO2 already confirm hypoventilation.
Question 8
An Orthodox Jewish patient with acute pancreatitis declines a CT scan scheduled for Yom Kippur. The interdisciplinary team insists the test is urgent. The patient tearfully states, "This feels like choosing between my faith and my life." How should the nurse respond?
- A) A) Contact hospital chaplain services to mediate the religious-care conflict
- B) B) Explain the medical necessity of the test to encourage compliance
- C) C) Advocate for rescheduling after verifying clinical stability with the provider✓
- D) D) Document the refusal and proceed with non-invasive alternatives
Show rationale
Option C balances spiritual needs and safety by confirming if delay is medically safe, aligning with AMSN's patient-centered care principles. Option A delegates communication without addressing care planning. Option B dismisses religious distress. Option D assumes alternatives exist without clinical validation. Discriminating cues: urgent but non-emergent scan timing versus high-holiday observance.
Question 9
A diabetic patient with heart failure (ejection fraction 40%) and NSAID-induced peptic ulcer history needs analgesia for bursitis. Which option balances efficacy and safety?
- A) A) Diclofenac 75 mg twice daily with omeprazole
- B) B) Piroxicam 20 mg daily with misoprostol
- C) C) Acetaminophen 1000 mg every 6 hours✓
- D) D) Celecoxib 200 mg daily with famotidine
Show rationale
Acetaminophen avoids NSAID risks: fluid retention worsening heart failure, ulcer recurrence, and renal impairment in diabetes. Adding GI protectants (A, B, D) reduces ulcer risk but doesn't mitigate heart failure exacerbation or kidney injury. Celecoxib (D) has lower ulcer risk but similar cardiovascular/renal hazards. Piroxicam (B) has a long half-life increasing toxicity. Guidelines (AHA) discourage NSAIDs in heart failure. Distractors prioritize ulcer prevention over cardiac/renal cues; C addresses all comorbidities safely.
Question 10
A nurse communicates via SBAR about a cirrhotic patient with hematemesis and INR of 3.2. What Background element is essential?
- A) A) Active vomiting of bright red blood requiring transfusion
- B) B) Suggest vitamin K administration and GI consultation
- C) C) Liver disease severity and anticoagulation status✓
- D) D) Systolic BP is 92 mmHg with heart rate 110 bpm
Show rationale
Background (B) must include context for bleeding risk. C provides cirrhosis and coagulopathy (elevated INR). A mixes Situation/Assessment. B is Recommendation. D is current vital signs. INR level and liver history are discriminating cues for hemorrhage management; guidelines emphasize historical context before intervention.
