Question Set B: Six Items, Six Item Types, Six Scoring Rules

Item 7 · Bowtie 0/1 · 5 points A client on the first postoperative day after a total abdominal hysterectomy suddenly reports shortness of breath. Respirations 30 breaths per minute, oxygen saturation 89 percent on room air, heart rate 122 beats per minute, sharp right-sided chest pain that worsens on inspiration, and a tender right calf. Place one condition, two actions to take, and two parameters to monitor.

Condition: 1. Pulmonary embolism 2. Atelectasis 3. Acute anxiety reaction 4. Spontaneous pneumothorax Actions to take, choose two: 1. Apply supplemental oxygen 2. Notify the surgeon and activate the rapid response team 3. Encourage hourly incentive spirometry 4. Massage the tender right calf 5. Lay the client flat and elevate both legs Parameters to monitor, choose two: 1. Oxygen saturation 2. Blood pressure 3. Bowel sounds 4. Incisional drainage 5. Serum sodium

Item 7 — Answer: Condition 1; Actions 1 and 2; Parameters 1 and 2 Why condition 1 is right: sudden dyspnea, pleuritic chest pain, tachycardia, and hypoxemia on the first postoperative day with a tender calf is the embolism picture. Why condition 2 is wrong: atelectasis develops gradually and does not produce sudden pleuritic pain with a tender calf. Why condition 3 is wrong: naming anxiety with a saturation of 89 percent explains the distress by dismissing the physiology. Why condition 4 is wrong: a pneumothorax after an abdominal procedure is unlikely and would not explain the calf finding. Why action 1 is right: hypoxemia is the finding with the shortest fuse and oxygen is within nursing scope. Why action 2 is right: every remaining intervention needs an order, and delay is the harm. Why action 3 is wrong: spirometry treats atelectasis and does nothing here. Why action 4 is wrong: massaging a calf with a suspected clot risks dislodging it. Why action 5 is wrong: flat with legs elevated worsens the work of breathing in an already hypoxemic client. Why parameter 1 is right: saturation is the direct measure of the failing function. Why parameter 2 is right: a falling blood pressure signals right heart strain and obstructive shock. Why parameter 3 is wrong: bowel sounds are a reasonable postoperative concern and track nothing about this problem. Why parameter 4 is wrong: incisional drainage belongs to the surgery, not to the sudden respiratory change. Why parameter 5 is wrong: serum sodium has no bearing on either the hypoxemia or the clot. The rule: Under zero-one scoring every cell is filled, because an empty cell and a wrong cell score the same and only one of them can earn.

Item 8 · Trend 0/1 · 1 point A client is receiving intravenous opioid by patient-controlled analgesia. 2200: respirations 16, oxygen saturation 97 percent on room air, awake and alert, heart rate 78. 0200: respirations 11, saturation 94 percent, drowsy but easily roused, heart rate 70. 0600: respirations 8, saturation 89 percent, difficult to rouse, heart rate 64. What changed, and what does it indicate?

1. The oxygen saturation alone has fallen, and the client needs incentive spirometry.
2. Respiratory rate, sedation level, and oxygen saturation are all moving in one direction, indicating opioid-induced respiratory depression.
3. The falling heart rate indicates an emerging dysrhythmia.
4. The values are acceptable, because no single reading is immediately life-threatening.

Item 8 — Answer: 2 Why 2 is right: three linked parameters moving the same way across three timestamps is a direction, and increasing sedation preceding a falling respiratory rate is the recognized sequence of opioid-induced respiratory depression. Why 1 is wrong: it isolates one value and ignores the sedation and rate changes moving with it. Why 3 is wrong: the heart rate change is small and is explained by the same sedation rather than by a new rhythm problem. Why 4 is wrong: judging each reading alone is snapshot reading, failure code F3. The rule: On a trend item the answer is a direction, and the distractors are usually the values that stayed flat.

Item 9 · Matrix grid, one per row 0/1 · 5 points A client arrives with new right-sided weakness and slurred speech that began 45 minutes ago. Mark each action as indicated, non-essential, or contraindicated.

1. Obtain a capillary blood glucose.
2. Keep the client with nothing by mouth until a swallow screen is completed.
3. Give aspirin by mouth on arrival, before imaging.
4. Insert an indwelling urinary catheter to track output.
5. Obtain a noncontrast head computed tomography scan before any antithrombotic is given.

Item 9 — Answer: 1 indicated, 2 indicated, 3 contraindicated, 4 non-essential, 5 indicated Why 1 is indicated: hypoglycemia mimics stroke, and it is ruled out in minutes. Why 2 is indicated: swallowing is unreliable until screened, and aspiration is the near-term harm. Why 3 is contraindicated: an antithrombotic before imaging may be given into a hemorrhagic stroke, and the client has not passed a swallow screen. Why 4 is non-essential: output monitoring is reasonable and a catheter is neither urgent nor required to obtain it. Why 5 is indicated: imaging separates the two stroke types, and the treatment paths diverge completely. The rule: Every row is answered, because an unanswered row under zero-one scoring is a point handed back.

Item 10 · Extended multiple response +/− · 3 points A 29-year-old client at 35 weeks gestation is receiving magnesium sulfate for preeclampsia. Select the three findings that require immediate follow-up.

1. Deep tendon reflexes now absent at the patellae, previously 2+.
2. Respirations 10 breaths per minute, down from 18 at the start of the infusion.
3. Reports feeling warm and flushed during the loading dose.
4. Urine output 20 mL over the last hour, down from 60 mL each hour.
5. Blood pressure 148/92 mm Hg, down from 162/104 on admission.
6. Mild drowsiness.
7. Reports mild nausea.
8. Fetal heart rate baseline 140 beats per minute with moderate variability.

Item 10 — Answer: 1, 2, 4 Why 1 is right: loss of deep tendon reflexes is the earliest sign of magnesium toxicity and precedes respiratory depression. Why 2 is right: a respiratory rate of 10 is the next stage of the same toxicity and needs the infusion stopped and the provider called. Why 4 is right: magnesium is cleared renally, so falling output means the drug is accumulating. Why 3 is wrong: warmth and flushing during the loading dose is expected and self-limiting. Why 5 is wrong: that blood pressure is improved from admission and is moving the right way. Why 6 is wrong: mild drowsiness alone is a common effect and carries no immediate action by itself. Why 7 is wrong: mild nausea is common and not time-critical. Why 8 is wrong: that fetal heart rate with moderate variability is reassuring. The rule: Under plus-minus scoring the stated number is a ceiling as well as a target, and a fourth uncertain click erases credit already earned.

Item 11 · Drop-down dyad RATIONALE · 1 point A client on the first day after a transurethral resection of the prostate has continuous bladder irrigation running. No drainage has entered the collection bag for two hours, the client reports suprapubic fullness and pain, and the bladder is distended on palpation. Earlier output was dark with visible clots. Complete the sentence.

The client is most likely experiencing [ 1. hypovolemia · 2. obstruction of the catheter by clots · 3. urinary tract infection · 4. acute kidney injury ] as evidenced by [ 1. a rising serum creatinine · 2. a distended bladder with suprapubic pain and no drainage while irrigation runs · 3. cloudy urine with a foul odor · 4. a heart rate that rose over two hours ].

Item 11 — Answer: 2 and 2 Why condition 2 is right: irrigation running in with nothing coming out, plus a distended and painful bladder, is mechanical obstruction until proven otherwise. Why condition 1 is wrong: hypovolemia produces low output from an empty bladder, not a distended one. Why condition 3 is wrong: infection does not stop drainage and would not distend the bladder this fast. Why condition 4 is wrong: kidney injury reduces urine production; here urine is being produced and cannot leave. Why evidence 2 is right: it is the only option that distinguishes obstruction from every other condition on the menu. Why evidence 1 is wrong: a rising creatinine supports kidney injury, not this condition. Why evidence 3 is wrong: cloudy, foul urine supports infection. Why evidence 4 is wrong: a rising heart rate is consistent with pain and with almost anything else, so it distinguishes nothing. The rule: Under rationale scoring a right condition with the wrong evidence earns nothing, so pick the evidence that only your condition explains.

Item 12 · Highlight in text +/− · 5 points Mark every phrase in this note that requires follow-up.

1800 · Six hours after total thyroidectomy. Client reports a tight feeling at the front of the neck and asks for the head of the bed to be raised. Voice hoarse and weaker than at 1400. Anterior neck dressing dry, but the posterior neck and pillow are damp on turning. Reports tingling around the mouth and in the fingertips. Describes swallowing as harder than earlier. Vital signs: temperature 98.8 °F, heart rate 92, respirations 18, blood pressure 128/76 mm Hg. —A. Reyes, RN

Item 12 — Answer: five phrases — "a tight feeling at the front of the neck"; "voice hoarse and weaker than at 1400"; "the posterior neck and pillow are damp on turning"; "tingling around the mouth and in the fingertips"; "swallowing as harder than earlier" Why the neck tightness is right: it is the earliest report of an expanding hematoma pressing on the airway. Why the hoarse, weakening voice is right: a voice changing across four hours signals nerve involvement or compression, and it has direction. Why the damp posterior neck and pillow is right: blood tracks behind the neck by gravity, so a dry front dressing does not rule out bleeding. Why the perioral and fingertip tingling is right: it is the first sign of hypocalcemia from parathyroid injury. Why the harder swallowing is right: it belongs to the same compression picture and confirms the direction. Why "asks for the head of the bed to be raised" is wrong: a comfort request is not itself a finding. Why "anterior neck dressing dry" is wrong: it is a normal finding, and marking normals is what plus-minus scoring punishes. Why the vital signs line is wrong: temperature 98.8 °F, heart rate 92, respirations 18, and blood pressure 128/76 mm Hg are all unremarkable here, and highlighting the line to be safe costs four deductions. The rule: Precision beats coverage; under plus-minus, marking normal findings takes back points your correct marks earned.

Score strip ITEM 7 ___ /5 · ITEM 8 ___ /1 · ITEM 9 ___ /5 · ITEM 10 ___ /3 · ITEM 11 ___ /1 · ITEM 12 ___ /5 · TOTAL ___ /20

Watch outItem 12 is the over-highlighting trap. Candidates who mark eight phrases instead of five commonly score lower than candidates who marked only three.

Margin notewhat did the blank cost you?

Scoring rules → BOOK 02 · P6. Item mechanics → BOOK 02 · P7.

TakeawayThe same uncertainty should produce a different click under each scoring rule, and this set proves whether that reflex exists yet.