Nursing Elites

1. A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion and release. For which potential complications should the nurse assess? (Select all that apply.)

• A. Urine output of 25 mL/hr
• B. Serum potassium level of 5.4 mEq/L
• C. Blood osmolality of 250 mOsm/L
• D.

Correct answer: A

Rationale:

2. A patient with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of which acid-base imbalance?

• A. Respiratory acidosis
• B. Respiratory alkalosis
• C. Increased PaCO2
• D. CNS disturbances

Correct answer: B

Rationale: The correct answer is B: Respiratory alkalosis. Hyperventilation, which can be caused by extreme anxiety, is the most common cause of acute respiratory alkalosis. This leads to a decrease in PaCO2 levels. Respiratory acidosis, choice A, occurs in conditions like hypoventilation, leading to an increase in PaCO2 levels. Choice C, Increased PaCO2, is not the correct term for an acid-base imbalance related to hyperventilation. Choice D, CNS disturbances, is not directly related to the acid-base imbalance caused by hyperventilation.

3. What is the most abundant positive ion in blood plasma?

• A. Potassium.
• B. Calcium.
• C. Sodium.
• D. Both potassium and sodium are in equal concentrations.

Correct answer: C

Rationale: The correct answer is C: Sodium. Sodium (Na+) is the most abundant cation in the extracellular fluid, including blood plasma. It plays a crucial role in maintaining fluid balance, nerve function, and is essential for various physiological processes. Choice A, Potassium, is also an important ion in the body but is predominantly found intracellularly. Choice B, Calcium, is an essential mineral in the body but is not the most abundant positive ion in blood plasma. Choice D is incorrect as sodium is the primary positive ion in blood plasma, with a much higher concentration compared to potassium.

4. . You are caring for a patient who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). Your patients plan of care includes assessment of specific gravity every 4 hours. The results of this test will allow the nurse to as

• A. Nutritional status
• B. Potassium balance
• C. Calcium balance
• D. Fluid volume status

Correct answer: D

Rationale:

5. A female patient is discharged from the hospital after having an episode of heart failure. She's prescribed daily oral doses of digoxin (Lanoxin) and furosemide (Lasix). Two days later, she tells her community health nurse that she feels weak and her heart 'flutters' frequently. What action should the nurse take?

• A. Tell the patient to rest more frequently.
• B. Advise the patient to discontinue digoxin and contact the physician.
• C. Contact the physician, report the symptoms, and request a blood sample to determine the patient's potassium level.
• D. Instruct the patient to avoid caffeine-containing foods.

Correct answer: C

Rationale: The correct action for the nurse to take is to contact the physician, report the patient's symptoms, and request a blood sample to determine the patient's potassium level. Furosemide, a potassium-wasting diuretic, can lead to hypokalemia, causing weakness and palpitations. Therefore, checking the potassium level is crucial in this situation. Simply telling the patient to rest more frequently won't address the underlying issue of potassium depletion. While digoxin can cause adverse effects, in this case, the symptoms are more likely related to furosemide-induced potassium loss. Instructing the patient to avoid caffeine-containing foods may be beneficial in general, but it wouldn't directly address the potassium depletion that needs urgent attention.

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