Nursing Elites

1. A diabetic patient's arterial blood gas (ABG) results are pH 7.28; PaCO2 34 mm Hg; PaO2 85 mm Hg; HCO3 18 mEq/L. The nurse would expect which finding?

• A. Intercostal retractions
• B. Kussmaul respirations
• C. Low oxygen saturation (SpO2)
• D. Decreased venous O2 pressure

Correct answer: B

Rationale: Kussmaul respirations (deep and rapid) are a compensatory mechanism for metabolic acidosis. The low pH and low bicarbonate levels indicate metabolic acidosis. Intercostal retractions, low oxygen saturation, and decreased venous O2 pressure are not associated with acidosis. Intercostal retractions typically occur in respiratory distress, while low oxygen saturation and decreased venous O2 pressure are more related to respiratory or circulatory issues, not metabolic acidosis.

2. Which of the following types of dressing changes works as a form of wound debridement?

• A. Dry dressing
• B. Transparent dressing
• C. Composite dressing
• D. Wet to dry dressing

Correct answer: D

Rationale: The correct answer is 'Wet to dry dressing.' Wet to dry dressing is a method of wound debridement that involves applying sterile soaked gauze to the wound, allowing it to dry and stick to the wound. When the dressing is removed, it pulls away drainage and debris, aiding in wound debridement. Choice A, 'Dry dressing,' does not actively assist in debridement as it does not collect or remove debris from the wound. Choice B, 'Transparent dressing,' is primarily used for maintaining a moist environment and wound observation, not for debridement. Choice C, 'Composite dressing,' combines multiple layers for different wound care purposes but is not specifically designed for debridement like wet to dry dressing.

3. A patient with severe mitral regurgitation and decreased cardiac output is being cared for by a nurse. The nurse assesses the patient for mental status changes. What is the rationale for this intervention?

• A. Decreased cardiac output can cause hypoxia to the brain
• B. Mental status changes may be a side effect of the patient's medication
• C. Mitral regurgitation is a complication associated with some neurological disorders
• D. The patient may be confused about his diagnosis

Correct answer: A

Rationale: When caring for a patient with severe mitral regurgitation and decreased cardiac output, assessing for mental status changes is crucial. Decreased cardiac output can lead to inadequate perfusion and oxygenation of vital organs, including the brain, resulting in hypoxia. This hypoxia can manifest as mental status changes such as confusion, restlessness, or lethargy. Therefore, monitoring mental status helps in identifying potential hypoxic states and guiding appropriate interventions. The other options are incorrect as they do not directly correlate decreased cardiac output with potential hypoxia-induced mental status changes.

4. What is a priority problem for a child with severe edema caused by nephrotic syndrome?

• A. Risk for constipation
• B. Risk for skin breakdown
• C. Inability to regulate body temperature
• D. Consuming more calories or nutrients than the body requires

Correct answer: B

Rationale: In nephrotic syndrome, characterized by massive proteinuria, hypoalbuminemia, and edema, a child with severe edema is at high risk for skin breakdown. The priority concern is to prevent skin breakdown by cleaning skin surfaces and ensuring adequate separation with clothing to avoid irritation. The child with nephrotic syndrome is typically anorexic, making consuming more calories or nutrients than necessary not a concern. Risk for constipation and inability to regulate body temperature are not primary issues associated with edema caused by nephrotic syndrome.

5. The nurse is caring for a 73-year-old man with cirrhosis. Which data obtained by the nurse during the assessment will be of most concern?

• A. The patient complains of right upper-quadrant pain upon palpation.
• B. The patient's hands flap back and forth when the arms are extended.
• C. The patient has ascites and a 2-kg weight gain from the previous day.
• D. The patient's skin has multiple spider-shaped blood vessels on the abdomen.

Correct answer: B

Rationale: The most concerning data obtained by the nurse is the patient's hands flapping back and forth when the arms are extended, indicating asterixis, which is associated with hepatic encephalopathy. This condition can progress to hepatic coma and requires immediate attention. The presence of spider angiomas and right upper-quadrant abdominal pain are common findings in cirrhosis and do not warrant urgent intervention. Although ascites and weight gain suggest the need for treatment, they are not as alarming as the neurologic manifestations seen in hepatic encephalopathy.

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