Nursing Elites

1. A client with elevated levels of antidiuretic hormone (ADH) triggers the release of this hormone due to which disorder?

• A. Pneumonia
• B. Dehydration
• C. Renal failure
• D. Edema

Correct answer: B

Rationale: Antidiuretic hormone (ADH) increases tubular permeability to water, causing more water absorption into the capillaries. ADH is released in response to a rising extracellular fluid osmolarity, such as in dehydration. Pneumonia, renal failure, and edema do not typically lead to the release of ADH. Pneumonia is an inflammatory lung condition, renal failure affects kidney function, and edema is the accumulation of excess fluid in the tissues, none of which directly stimulate the release of ADH.

2. A client is being prepared for transfer to the operating room. Which of the following actions should the nurse take in the care of this client at this time?

• A. Ensuring that the client has voided
• B. Administering all daily medications
• C. Practicing postoperative breathing exercises
• D. Verifying that the client has not eaten for the last 24 hours

Correct answer: A

Rationale: The nurse should ensure that the client has voided, especially if a Foley catheter is not in place. This step is important to prevent urinary retention during the surgical procedure. Administering all daily medications just before surgery is not standard practice. The physician typically provides specific orders regarding which medications can be taken with a sip of water before surgery. Postoperative breathing exercises are usually taught after surgery to prevent complications like atelectasis. Verifying that the client has not eaten for the last 24 hours is not a standard preoperative practice; instead, the client is usually instructed to fast for a specific period before surgery to reduce the risk of aspiration during anesthesia.

3. Blood for arterial blood gas determinations is drawn from a client with pneumonia, and testing reveals a pH of 7.45, PCO2 of 30 mm Hg, and HCO3 of 19 mEq/L. The nurse interprets these results as indicative of:

• A. Compensated metabolic acidosis
• B. Compensated respiratory alkalosis
• C. Uncompensated metabolic alkalosis
• D. Uncompensated respiratory acidosis

Correct answer: B

Rationale: The correct answer is 'Compensated respiratory alkalosis.' In this case, the client's pH is within the normal range (7.35-7.45), indicating compensation. The low PCO2 (30 mm Hg) suggests respiratory alkalosis, while the low HCO3 (19 mEq/L) is also consistent with a compensatory response. Therefore, the client has a primary respiratory alkalosis that is being compensated for by metabolic acidosis. Choices A, C, and D are incorrect because they do not fit the pattern of the given blood gas values, which indicate respiratory alkalosis with metabolic compensation.

4. Which of the following is a key symptom of appendicitis?

• A. Right lower quadrant pain.
• B. Left lower quadrant pain.
• C. Generalized abdominal pain.
• D. Rebound tenderness.

Correct answer: A

Rationale: Corrected Choice A: Right lower quadrant pain is a classic and key symptom of appendicitis. Pain in the right lower quadrant is typically the initial symptom and is a result of inflammation and irritation of the appendix. This pain can start around the umbilicus and then migrate to the right lower quadrant. It is important to note that appendicitis rarely presents with pain in the left lower quadrant or generalized abdominal pain. Rebound tenderness, indicated in Choice D, is a sign of peritoneal irritation and is associated with appendicitis, but it is not as characteristic as the right lower quadrant pain in the initial presentation of appendicitis.

5. The adult client admitted to the post-anesthesia care unit (PACU) following abdominal surgery has a tympanic temperature of 94.6°F (34.8°C), a pulse rate of 88 beats/minute, a respiratory rate of 14 breaths/minute, and a blood pressure of 94/64 mmHg. Which action should the nurse implement?

• A. Take the client's temperature using another method.
• B. Raise the head of the bed to 60 to 90 degrees.
• C. Ask the client to cough and deep breathe.
• D. Check the blood pressure every five minutes for one hour.

Correct answer: A

Rationale: Taking the client's temperature using another method is the most appropriate action in this situation. A tympanic temperature of 94.6°F (34.8°C) is abnormally low and may not reflect the true core body temperature accurately. By using an alternative method, such as oral or rectal temperature measurement, the nurse can obtain a more reliable temperature reading. Raising the head of the bed (Choice B) is not directly related to addressing the low temperature. Asking the client to cough and deep breathe (Choice C) may be beneficial for respiratory function but does not address the temperature concern. Checking the blood pressure every five minutes for one hour (Choice D) is not the priority when the initial focus should be on accurate temperature assessment.

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