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. A nurse assesses a client who is prescribed furosemide (Lasix) for hypertension. For which acid-base imbalance should the nurse assess to prevent complications of this therapy?

• A. Respiratory acidosis
• B. Respiratory alkalosis
• C. Metabolic acidosis
• D. Metabolic alkalosis

Correct answer: D

Rationale:

3. A nurse is visiting an 84-year-old woman living at home and recovering from hip surgery. The woman seems confused and has poor skin turgor, and she states that 'she stops drinking water early in the day because it is too difficult to get up during the night to go to the bathroom.' The nurse explains to the woman that:

• A. She will need to have her medications adjusted and be readmitted to the hospital for a complete workup.
• B. Limiting fluids can create imbalances in the body that can result in confusion; maybe we need to adjust the timing of your fluids.
• C. It is normal to be a little confused following surgery and it is safe not to urinate at night.
• D. Confusion following surgery is common in the elderly due to loss of sleep.

Correct answer: B

Rationale: The correct answer is B. In elderly patients, fluid deficits can lead to confusion and cognitive impairment. Limiting fluids can disrupt the body's balance, leading to such symptoms. Adjusting the timing of fluids can help maintain hydration without causing nighttime interruptions. Choices A, C, and D are incorrect because they do not address the underlying issue of fluid imbalance causing confusion. Choice A suggests unnecessary hospital readmission and medication adjustments. Choice C incorrectly normalizes confusion post-surgery and suggests it is safe not to urinate at night, which can exacerbate the issue. Choice D inaccurately attributes confusion to sleep loss rather than fluid imbalance.

4. You are an emergency-room nurse caring for a trauma patient. Your patient has the following arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How would you interpret these results?

• A. Respiratory acidosis with no compensation
• B. Metabolic alkalosis with a compensatory alkalosis
• C. Metabolic acidosis with no compensation
• D. Metabolic acidosis with a compensatory respiratory alkalosis

Correct answer: D

Rationale: A low pH indicates acidosis (normal pH is 7.35 to 7.45). The PaCO2 is also low, which causes alkalosis. The bicarbonate is low, which causes acidosis. The pH bicarbonate more closely corresponds with a decrease in pH, making the metabolic component the primary problem. Therefore, the correct interpretation of the arterial blood gas results is metabolic acidosis with a compensatory respiratory alkalosis. Choices A, B, and C are incorrect because they do not accurately reflect the primary acid-base disturbance and the compensatory response seen in the given results.

5. You are working on a burns unit, and one of your acutely ill patients is exhibiting signs and symptoms of third spacing. Based on this change in status, you should expect the patient to exhibit signs and symptoms of what imbalance?

• A. Metabolic alkalosis
• B. Hypermagnesemia
• C. Hypercalcemia
• D. Hypovolemia

Correct answer: D

Rationale: When a patient exhibits signs and symptoms of third-spacing, where fluid moves out of the intravascular space but not into the intracellular space, hypovolemia is expected. This leads to a decreased circulating blood volume. Increased calcium and magnesium levels are not typically associated with third-spacing fluid shift. Burns usually result in acidosis rather than alkalosis, making metabolic alkalosis an incorrect choice. Therefore, hypovolemia is the correct answer in this scenario.

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