Nursing Elites

1. A 15-year-old high school wrestler has been taking diuretics to lose weight to compete in a lower weight class. Which of the following medical tests is most likely to be given?

• A. Lab values of Potassium and Sodium
• B. Lab values of Glucose and Hemoglobin
• C. ECG
• D. CT scan

Correct answer: A

Rationale: Diuretics can disrupt the sodium and potassium balance, potentially leading to cardiac complications. Monitoring the lab values of potassium and sodium is crucial to assess electrolyte imbalances due to diuretic use. Testing glucose and hemoglobin levels is not directly related to diuretic use in this context. An ECG would be indicated if there were signs or symptoms of cardiac abnormalities, but it is not the primary test to monitor the effects of diuretics. A CT scan is not typically used to assess electrolyte imbalances caused by diuretics.

2. The client is scheduled for surgical repair of a detached retina. What is the most likely preoperative nursing diagnosis for this client?

• A. Anxiety related to loss of vision and potential failure to regain vision.
• B. Deficient knowledge (preoperative and postoperative activities) related to lack of information.
• C. Acute pain related to tissue injury and decreased circulation to the eye.
• D. Risk for infection related to the eye injury.

Correct answer: A

Rationale: The correct preoperative nursing diagnosis for a client scheduled for surgical repair of a detached retina is 'Anxiety related to loss of vision and potential failure to regain vision.' A client facing the threat of permanent blindness due to a detached retina is likely to experience anxiety. Addressing this anxiety is crucial before providing education, as severe anxiety can hinder the client's ability to absorb new information. The nurse should offer emotional support, encourage the client to express concerns, and clarify any misconceptions. Acute pain is not a typical symptom of a detached retina, and the risk of infection preoperatively is minimal, making choices C and D less relevant in this scenario.

3. The nurse is caring for a client who is 28 weeks pregnant and complains of swollen hands and feet. Which symptom below would cause the greatest concern?

• A. Nasal congestion
• B. Hiccups
• C. Blood glucose of 150
• D. Muscle spasms

Correct answer: D

Rationale: The correct answer is muscle spasms because they can be indicative of a severe condition like preeclampsia, which is a serious complication during pregnancy characterized by high blood pressure and signs of damage to another organ system, most often the liver and kidneys. Nasal congestion and hiccups are common discomforts during pregnancy and do not pose a severe risk to the client or fetus. A blood glucose level of 150, while slightly elevated, may not be alarming in a pregnant individual and can be managed through dietary modifications or medication adjustments. Muscle spasms, especially in the context of pregnancy, should be taken seriously and thoroughly assessed to rule out any underlying serious conditions.

4. While assessing a patient in the ICU, a nurse observes signs of a weak pulse, quick respiration, acetone breath, and nausea. Which of the following conditions is most likely occurring?

• A. Hypoglycemic patient
• B. Hyperglycemic patient
• C. Cardiac arrest
• D. End-stage renal failure

Correct answer: B

Rationale: The correct answer is a hyperglycemic patient. The signs described - weak pulse, quick respiration, acetone breath, and nausea - are indicative of hyperglycemia. A hypoglycemic patient would typically present with different signs such as pale skin, sweating, and confusion. Cardiac arrest would manifest with sudden loss of heart function and consciousness, not the signs described. End-stage renal failure would present with symptoms related to kidney dysfunction like edema, fatigue, and changes in urine output, which are not mentioned in the scenario.

5. A client goes to the Emergency Department with acute respiratory distress and the following arterial blood gases (ABGs): pH 7.35, PCO2 40 mmHg, PO2 63mmHg, HCO3 23, and oxygenation saturation (SAO2) 93%. Which of the following represents the best analysis of the etiology of these ABGs?

• A. tuberculosis (TB)
• B. pneumonia
• C. pleural effusion
• D. hypoxia

Correct answer: D

Rationale: A combined low PO2 and low SAO2 indicates hypoxia. The pH, PCO2, and HCO3 are normal. ABGs are not necessarily altered in TB or pleural effusion. In pneumonia, the PO2 and PCO2 might be low because hypoxia stimulates hyperventilation, but the best analysis in this case is hypoxia due to the combination of low PO2 and low SAO2.

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