Nursing Elites

1. A nurse assesses a client who is experiencing an acid-base imbalance. The clients arterial blood gas values are pH 7.34, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3 19 mEq/L. Which assessment should the nurse perform first?

• A. . Cardiac rate and rhythm
• B. Skin and mucous membranes
• C. Musculoskeletal strength
• D. Level of orientation

Correct answer: A

Rationale:

2. A nurse is caring for a client who has the following laboratory results: potassium 3.4 mEq/L, magnesium 1.8 mEq/L, calcium 8.5 mEq/L, sodium 144 mEq/L. Which assessment should the nurse complete first?

• A. Assess the client's dietary intake of foods high in potassium.
• B. Assess the client's neuromuscular status.
• C. Assess the client's fluid intake and output.
• D. Read food labels to determine sodium content.

Correct answer: D

Rationale: The correct answer is to read food labels to determine sodium content. The client's sodium level is crucial to monitor as it is on the higher side (144 mEq/L), which can indicate hypernatremia. Excessive sodium intake can lead to fluid retention and other complications. Assessing dietary sodium intake can help the nurse and client make necessary adjustments to prevent further sodium imbalances. Choices A, B, and C are not the priority in this situation as the client's sodium level needs immediate attention to prevent potential complications.

3. . You are caring for a patient who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). Your patients plan of care includes assessment of specific gravity every 4 hours. The results of this test will allow the nurse to as

• A. Nutritional status
• B. Potassium balance
• C. Calcium balance
• D. Fluid volume status

Correct answer: D

Rationale:

4. A nurse is assessing a client who has acute pancreatitis and is at risk for an acid-base imbalance. For which manifestation of this acid-base imbalance should the nurse assess?

• A. Agitation
• B. Kussmaul respirations
• C. Seizures
• D. Positive Chvosteks sign

Correct answer: B

Rationale:

5. You are caring for a patient who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). Your patient's plan of care includes assessment of specific gravity every 4 hours. The results of this test will allow the nurse to assess what aspect of the patient's health?

• A. Nutritional status
• B. Potassium balance
• C. Calcium balance
• D. Fluid volume status

Correct answer: D

Rationale: Assessing the specific gravity in a patient with SIADH helps the nurse evaluate the patient's fluid volume status. Specific gravity indicates the concentration of solutes in the urine and can detect if the patient has a fluid volume deficit or excess. Nutritional status, potassium balance, and calcium balance are not directly assessed through specific gravity testing. Nutritional status is typically evaluated through dietary intake and anthropometric measurements. Potassium balance is assessed through blood tests and ECG monitoring. Calcium balance is evaluated through blood tests and bone density scans. Therefore, the correct answer is assessing fluid volume status through specific gravity testing.

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