Respiratory assessment and failure are core med-surg competencies the CMSRN tests. Practice the pneumonia, ARDS, and oxygenation scenarios below, each with a full rationale.
Question 1
A 68-year-old with heart failure (ejection fraction 30%) and stage 3 CKD reports 3.5 kg weight gain over 48 hours and dyspnea at rest. Vital signs: BP 160/92 mmHg, O2 sat 89% on room air. Furosemide was increased yesterday without effect. Which care plan revision is most appropriate?
- A) A) Add hydrochlorothiazide and schedule daily weights
- B) B) Initiate IV bumetanide and continuous pulse oximetry✓
- C) C) Increase furosemide dosage and restrict fluid to 1L/day
- D) D) Maintain current diuretic and order renal function tests
Show rationale
B is correct due to acute decompensation (rapid weight gain, dyspnea at rest, hypoxia) and CKD limiting oral diuretic efficacy. IV bumetanide achieves faster diuresis in renal impairment. Continuous oximetry monitors respiratory compromise. A is inadequate: hydrochlorothiazide is less effective in CKD and ignores hypoxia. C is unsafe: further oral furosemide may cause toxicity without addressing oxygenation. D delays intervention despite worsening symptoms. CMSRN standards prioritize rapid response to acute fluid overload with renal considerations.
Question 2
A transgender patient admitted for pneumonia is repeatedly misgendered by staff. They withdraw during assessments and state, "I'm tired of correcting people." Which action demonstrates therapeutic communication?
- A) A) Apologize privately and place a gender-affirming sign on the door
- B) B) Educate the care team about pronouns during handoff report
- C) C) Validate their frustration and co-create a unit-wide pronoun plan✓
- D) D) Report the incidents to hospital diversity officers immediately
Show rationale
Option C actively listens to expressed exhaustion ("tired of correcting") and promotes collaborative solutions, fostering trust. Option A isolates resolution to the nurse-patient dyad. Option B delays action and shifts responsibility. Option D escalates administratively without direct patient input. AMSN standards emphasize affirming identity through inclusive communication and partnership.
Question 3
During bronchoscopy on a patient with suspected COVID-19 pneumonia, an aerosol-generating procedure is initiated. The nurse wears an N95 respirator. Which additional action is critical?
- A) A) Use a face shield with disposable gown and gloves✓
- B) B) Switch to a PAPR unit with integrated eye protection
- C) C) Double-mask with a surgical mask over the N95
- D) D) Activate UV disinfection during the procedure
Show rationale
Aerosol-generating procedures (e.g., bronchoscopy) increase COVID-19 transmission risk. CDC mandates N95 respirators plus eye protection, gown, and gloves. Option A provides comprehensive barrier protection. Option B is unnecessary if N95 is properly fitted. Option C offers no added benefit. Option D isn't immediate PPE. Suspected COVID-19 requires enhanced droplet/contact precautions during aerosols.
Question 4
A 75-year-old with severe COPD (FEV1 45% predicted) and osteoporosis uses home oxygen at 2L/min. Pre-op teaching for total knee replacement includes incentive spirometry. Which instruction is critical?
- A) A) Perform spirometry hourly while awake with oxygen disconnected.
- B) B) Use spirometry every 2 hours without changing oxygen flow.
- C) C) Complete spirometry 10 times/hour using nasal cannula oxygen.✓
- D) D) Attempt spirometry 5 times hourly after bronchodilator use.
Show rationale
COPD patients need oxygenation maintained during spirometry to prevent hypoxia. Option A risks desaturation by removing oxygen. Option B’s frequency is insufficient for lung expansion. Option D adds unnecessary bronchodilators without indication. Maintaining oxygen (cue) and adequate repetition (cue) aligns with pulmonary guidelines for high-risk patients.
Question 5
A 68-year-old patient with severe OSA (using home CPAP) and hypertension emerges from general anesthesia after abdominal surgery. Upon PACU arrival, they have snoring respirations at 8 breaths/min and SpO₂ 88% on 2L nasal cannula. Which intervention aligns with current ASA practice guidelines?
- A) A) Increase oxygen to 6L nasal cannula while maintaining current positioning
- B) B) Perform jaw thrust and insert oral airway while preparing for CPAP application✓
- C) C) Administer naloxone 0.04mg IV to reverse opioid-induced respiratory depression
- D) D) Initiate non-rebreather mask at 15L and notify anesthesia for reintubation
Show rationale
Jaw thrust with airway adjunct addresses obstruction from OSA and sedation residuals, aligning with ASA guidelines prioritizing airway maneuvers before oxygenation escalation. Option A ignores obstruction risk and may cause CO₂ retention. Option C incorrectly assumes opioid cause despite slow rate not matching typical overdose. Option D skips basic maneuvers and escalates care prematurely. OSA history and low respiratory rate are key cues requiring immediate obstruction relief before oxygenation adjustments.
Question 6
On post-op day 1 after abdominal surgery, a patient with opioid-naïve status and chronic back pain develops shallow respirations (RR 10/min) and rates pain 8/10. The nurse notes guarding and grimacing. Which relaxation technique aligns with ASPAN guidelines for early mobilization?
- A) A) Progressive muscle relaxation with sequential tensing
- B) B) Guided imagery of a beach scene with deep breathing
- C) C) Incentive spirometer coaching with sustained inspiration✓
- D) D) Mindfulness meditation focusing on body sensations
Show rationale
Incentive spirometry promotes lung expansion and pain control through controlled inspiration, directly supporting post-op mobilization per ASPAN guidelines. Guarding indicates splinting, which IS counters by encouraging deep breaths. Muscle relaxation (A) risks incisional strain during tensing. Guided imagery (B) and mindfulness (D) lack immediate physiological impact on alveolar recruitment. Sustained inspiration in IS improves oxygenation and pain perception without opioid use, critical for opioid-naïve patients.
Question 7
An 82-year-old with moderate Alzheimer's disease is hospitalized for pneumonia and has reduced oral intake. Which individualized intervention best addresses hydration needs?
- A) A) Offer 120 mL water hourly during waking hours using a clear cup✓
- B) B) Administer IV fluids at 75 mL/hr until oral intake improves
- C) C) Provide thickened liquids via syringe every 2 hours
- D) D) Encourage family to give sips between meals as tolerated
Show rationale
Cognitive impairment requires structured, visual cues (clear cup) for hydration, avoiding invasive methods while promoting independence (NIA guidelines). IV fluids (B) increase infection risk and aren't first-line for alert patients. Thickened liquids (C) address dysphagia, not indicated here. Family-dependent intake (D) is unreliable for measurable goals. The cues (Alzheimer's, pneumonia, reduced intake) prioritize non-invasive, scheduled oral hydration to prevent delirium and support recovery.
Question 8
A 75-year-old with COPD, osteoporosis, and mild cognitive impairment is discharged post-pneumonia hospitalization. The patient uses a walker and lives alone in a multilevel home. Which care coordination strategy best reduces readmission risk while considering value-based purchasing implications?
- A) A) Coordinating outpatient pulmonary rehab and prescribing supplemental oxygen
- B) B) Arranging a home safety evaluation and physical therapy for stair negotiation✓
- C) C) Scheduling a pharmacy consult for inhaler education and medication synchronization
- D) D) Providing written pneumonia prevention guidelines and a follow-up appointment
Show rationale
Falls in elderly patients with osteoporosis significantly increase readmission risks and costs. The home safety eval and stair training (B) directly address environmental hazards and mobility limitations, preventing injury-related readmissions. Pulmonary rehab (A) and inhaler education (C) manage COPD but ignore the immediate fall risk from impaired mobility and home layout. Pneumonia prevention (D) is general and doesn't mitigate the specific fall hazard. CMS links reimbursement to preventing hospital-acquired conditions like falls, making (B) the most targeted intervention.
Question 9
A 68-year-old with advanced Parkinson's disease is admitted for aspiration pneumonia. The patient has progressive dysphagia, a body mass index of 18, and family reports reduced medication adherence. Which interdisciplinary team member should coordinate long-term enteral feeding options and medication administration adjustments?
- A) A) Speech-language pathologist to assess swallowing safety and recommend diet modifications
- B) B) Registered dietitian to calculate caloric needs and initiate oral supplements
- C) C) Clinical pharmacist to evaluate drug-nutrient interactions and crushing feasibility✓
- D) D) Case manager to arrange home health for IV antibiotic administration
Show rationale
The pharmacist addresses both discriminating cues: dysphagia complicates oral medication administration, and malnutrition requires feeding route evaluation. While the SLP focuses on swallowing safety (A), they don't address medication adjustments. The dietitian manages nutrition (B) but not drug compatibility. Case management (D) coordinates services but lacks expertise in drug-nutrient issues. Pharmacists uniquely integrate medication pharmacokinetics with feeding access per ASPEN guidelines, ensuring safe levodopa delivery via alternative routes.
Question 10
A 45-year-old construction worker with low health literacy is readmitted for COPD exacerbation after repeatedly missing inhaler doses. He states, "I forget when I'm busy." Which goal-setting strategy is most effective?
- A) A) Schedule a family meeting to assign medication supervision responsibilities
- B) B) Use pictogram-based checklists tied to his work break schedule✓
- C) C) Provide detailed written instructions about inhaler mechanisms
- D) D) Set a goal for 100% adherence without discussing barriers
Show rationale
B addresses both cues: low literacy (via visuals) and busy work schedule (cue) by linking medication to existing routines. A inappropriately delegates responsibility without patient consent. C ignores literacy barriers and lacks practicality. D is punitive and neglects root causes. Health literacy standards recommend matching tools to patient capabilities; B adapts to his job rhythm while simplifying instructions. A/C/D fail to address the forgetfulness-workload connection central to his readmission.
