Nursing Elites

1. A nurse evaluates the following arterial blood gas values in a client: pH 7.48, PaO2 98 mm Hg, PaCO2 28 mm Hg, and HCO3 22 mEq/L. Which client condition should the nurse correlate with these results?

• A. Diarrhea and vomiting for 36 hours
• B. . Anxiety-induced hyperventilation
• C. Chronic obstructive pulmonary disease (COPD)
• D. Diabetic ketoacidosis and emphysema

Correct answer: B

Rationale:

2. While assessing a clients peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 4-cm venous cord. How should the nurse document this finding?

• A. Grade 3 phlebitis at IV site
• B. infection at IV site
• C. Thrombosed area at IV site
• D. infiltration at IV site

Correct answer: A

Rationale:

3. A nurse is caring for a client who has a serum calcium level of 14 mg/dL. Which provider order should the nurse implement first?

• A. Encourage oral fluid intake.
• B. Connect the client to a cardiac monitor.
• C. Assess urinary output.
• D. Administer oral calcitonin (Calcimar).

Correct answer: A

Rationale: The correct answer is to encourage oral fluid intake. With a serum calcium level of 14 mg/dL, the client is at risk of hypercalcemia. Encouraging oral fluid intake helps to promote hydration and can help prevent further elevation of calcium levels. Connecting the client to a cardiac monitor (Choice B) is important but not the first priority in this situation. Assessing urinary output (Choice C) is relevant but does not address the immediate concern of high serum calcium levels. Administering oral calcitonin (Calcimar) (Choice D) may be a treatment option later, but the first step should be to address hydration.

4. You are performing an admission assessment on an older adult patient newly admitted for end-stage liver disease. What principle should guide your assessment of the patient's skin turgor?

• A. Overhydration is common among healthy older adults.
• B. Dehydration causes the skin to appear spongy.
• C. Inelastic skin turgor is a normal part of aging.
• D. Skin turgor cannot be assessed in patients over 70.

Correct answer: C

Rationale: Inelastic skin is a normal change of aging. However, this does not mean that skin turgor cannot be assessed in older patients. Dehydration, not overhydration, causes inelastic skin with tenting. Overhydration, not dehydration, causes the skin to appear edematous and spongy. Choice A is incorrect because overhydration is not common among healthy older adults. Choice B is incorrect because dehydration leads to inelastic skin, not sponginess. Choice D is incorrect as skin turgor assessment can be done in patients of any age, including those over 70.

5. A medical-surgical nurse is concerned about the incidence of complications related to IV therapy, including bloodstream infection. Which intervention should the nurse suggest to the management team to make the biggest impact on decreasing complications

• A. Initiate a dedicated team to insert access devices
• B. . Require additional education for all nurses.
• C. Limit the use of peripheral venous access devices.
• D. Perform quality control testing on skin preparation products.

Correct answer: A

Rationale:

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