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. 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.

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. What is the priority assessment for a patient receiving intravenous morphine?

• A. Assessing the patient's blood pressure.
• B. Monitoring the patient's respiratory rate.
• C. Checking the patient's pain level.
• D. Monitoring the patient's oxygen saturation.

Correct answer: B

Rationale: The correct answer is monitoring the patient's respiratory rate. When a patient receives intravenous morphine, the priority assessment is to monitor the respiratory rate due to the risk of respiratory depression associated with morphine. This assessment helps in detecting and managing any potential respiratory complications promptly. Assessing blood pressure, checking pain level, and monitoring oxygen saturation are important aspects of patient care but are not the priority when considering the specific risk of respiratory depression with intravenous morphine.

5. A client is experiencing diarrhea. For which acid-base disorder should the nurse assess the client?

• A. Metabolic acidosis
• B. Metabolic alkalosis
• C. Respiratory acidosis
• D. Respiratory alkalosis

Correct answer: A

Rationale: When a client experiences diarrhea, the loss of bicarbonate-rich fluids from the body leads to a decrease in the bicarbonate levels in the blood, resulting in metabolic acidosis. Metabolic alkalosis (choice B) is characterized by an increase in bicarbonate levels, which is not typically associated with diarrhea. Respiratory acidosis (choice C) is caused by retention of carbon dioxide, while respiratory alkalosis (choice D) results from excessive exhalation of carbon dioxide, neither of which are directly related to diarrhea. Therefore, the correct answer is metabolic acidosis (choice A) in the context of diarrhea.

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