Nursing Elites

1. 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:

2. The baroreceptors, located in the left atrium and in the carotid and aortic arches, respond to changes in the circulating blood volume and regulate sympathetic and parasympathetic neural activity as well as endocrine activities. Sympathetic stimulation constricts renal arterioles, causing what effect?

• A. Decrease in the release of aldosterone
• B. Increase of filtration in the Loop of Henle
• C. Decrease in the reabsorption of sodium
• D. Decrease in glomerular filtration

Correct answer: D

Rationale:

3. A nurse is planning care for a client who is hyperventilating. The clients arterial blood gas values are pH 7.30, PaO2 94 mm Hg, PaCO2 31 mm Hg, and HCO3 26 mEq/L. Which question should the nurse ask when developing this clients plan of care?

• A. Do you take any over-the-counter medications?
• B. You appear anxious. What is causing your distress?
• C. Do you have a history of anxiety attacks?
• D. You are breathing fast. Is this causing you to feel light-headed?

Correct answer: B

Rationale:

4. What would be the best initial nursing action prior to inserting an IV?

• A. Instruct the patient to wash their hands.
• B. Prepare the IV insertion site with povidone iodine.
• C. Verify the order for IV therapy.
• D. Identify a suitable vein.

Correct answer: C

Rationale: The best initial nursing action prior to inserting an IV is to verify the order for IV therapy. This step ensures that the IV insertion is appropriate and necessary based on the physician's orders. Instructing the patient to wash their hands (Choice A) is important for infection control but not the immediate priority before IV insertion. While preparing the IV insertion site with povidone iodine (Choice B) and identifying a suitable vein (Choice D) are crucial steps in the process, confirming the order for IV therapy (Choice C) takes precedence to ensure the correct intervention is being performed.

5. A nurse in the medical-surgical unit is giving a patient with low blood pressure a hypertonic solution, which will increase the number of dissolved particles in his blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. Which of the following terms is associated with this process?

• A. Hydrostatic pressure
• B. Osmosis and osmolality
• C. Diffusion
• D. Active transport

Correct answer: B

Rationale: Osmosis is the movement of fluid from a region of low solute concentration to a region of high solute concentration across a semipermeable membrane. The number of dissolved particles contained in a unit of fluid determines the osmolality of a solution, which influences the movement of fluid between the fluid compartments. Giving a patient who has low blood pressure a hypertonic solution will increase the number of dissolved particles in the blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. Option A is incorrect; hydrostatic pressure refers to changes in water or volume related to water pressure. Option C is incorrect; diffusion is the movement of solutes from an area of greater concentration to lesser concentration. The solutes in an intact vascular system are unable to move, so diffusion should not normally take place. Option D is incorrect; active transport is the movement of molecules against the concentration gradient and requires ATP as an energy source. This process typically takes place at the cellular level and is not involved in vascular volume changes.

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