Nursing Elites

1. You are making initial shift assessments on your patients. While assessing one patients peripheral IV site, you note edema around the insertion site. How should you document this complication related to IV therapy?

• A. Air emboli
• B. Phlebitis
• C. Infiltration
• D. Fluid overload

Correct answer: C

Rationale:

2. Third spacing occurs when fluid moves out of the intravascular space but not into the intracellular space. Based on this fluid shift, the nurse will expect the patient to demonstrate:

• A. Hypertension
• B. Bradycardia
• C. Hypervolemia
• D. Hypovolemia

Correct answer: D

Rationale: In the scenario of third-spacing fluid shift, where fluid moves out of the intravascular space but not into the intracellular space, the patient is expected to demonstrate hypovolemia. Hypertension (Choice A) is unlikely as hypovolemia typically leads to decreased blood pressure. Bradycardia (Choice B) is not a common manifestation of hypovolemia, as the body often tries to compensate by increasing heart rate. Hypervolemia (Choice C) indicates an excess of fluid, which is the opposite of what occurs in third spacing.

3. A nurse is caring for a client who has the following arterial blood values: pH 7.12, PaO2 56 mm Hg, PaCO2 65 mm Hg, and HCO3 22 mEq/L. Which clinical situation should the nurse correlate with these values?

• A. . Diabetic ketoacidosis in a person with emphysema
• B. Bronchial obstruction related to aspiration of a hot dog
• C. Anxiety-induced hyperventilation in an adolescen
• D. Diarrhea for 36 hours in an older, frail woman

Correct answer: A

Rationale:

4. The ICU nurse is caring for a patient who experienced trauma in a workplace accident. The patient is complaining of having trouble breathing with abdominal pain. An ABG reveals the following results: pH 7.28, PaCO2 50 mm Hg, HCO3 23 mEq/L. The nurse should recognize the likelihood of what acidbase disorder?

• A. Respiratory acidosis
• B. Metabolic alkalosis
• C. Respiratory alkalosis
• D. Mixed acidbase disorder

Correct answer: D

Rationale:

5. You are performing an admission assessment on an older adult patient newly admitted for end-stage liver disease. What principle should guide your assessment of the patients skin turgor?

• A. Overhydration is common among healthy older adults.
• B. Dehydration causes the skin to appear spongy
• C. Inelastic skin turgor is a normal part of aging
• D. Skin turgor cannot be assessed in patients over 70.

Correct answer: C

Rationale:

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