Nursing Elites

1. A patient is taking spironolactone (Aldactone) to control her hypertension. Her serum potassium level is 6 mEq/L. For this patient, the nurse's priority would be to assess her:

• A. Neuromuscular function
• B. Bowel sounds
• C. Respiratory rate
• D. Electrocardiogram (ECG) results

Correct answer: D

Rationale: In a patient with a serum potassium level of 6 mEq/L due to spironolactone use, the nurse's priority is to assess the Electrocardiogram (ECG) results. Hyperkalemia can lead to life-threatening arrhythmias, such as ventricular fibrillation, which can be detected on an ECG. While changes in neuromuscular function, bowel sounds, and respiratory rate can occur with hyperkalemia, the most critical assessment related to the patient's condition would be monitoring the ECG for signs of cardiac complications.

2. . A 73-year-old man comes into the emergency department (ED) by ambulance after slipping on a small carpet in his home. The patient fell on his hip with a resultant fracture. He is alert and oriented; his pupils are equal and reactive to light and accommodation. His heart rate is elevated, he is anxious and thirsty, a Foley catheter is placed, and 40 mL of urine is present. What is the nurses most likely explanation for the low urine output?

• A. The man urinated prior to his arrival to the ED and will probably not need to have the Foley catheter kept in place.
• B. The man likely has a traumatic brain injury, lacks antidiuretic hormone (ADH), and needs vasopressin.
• C. The man is experiencing symptoms of heart failure and is releasing atrial natriuretic peptide that results in decreased urine output.
• D. The man is having a sympathetic reaction, which has stimulated the reninangiotensinaldosterone system that results in diminished urine output.

Correct answer: D

Rationale:

3. You are an emergency-room nurse caring for a trauma patient. Your patient has the following arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How would you interpret these results?

• A. Respiratory acidosis with no compensation
• B. Metabolic alkalosis with a compensatory alkalosis
• C. Metabolic acidosis with no compensation
• D. Metabolic acidosis with a compensatory respiratory alkalosis

Correct answer: D

Rationale: A low pH indicates acidosis (normal pH is 7.35 to 7.45). The PaCO2 is also low, which causes alkalosis. The bicarbonate is low, which causes acidosis. The pH bicarbonate more closely corresponds with a decrease in pH, making the metabolic component the primary problem. Therefore, the correct interpretation of the arterial blood gas results is metabolic acidosis with a compensatory respiratory alkalosis. Choices A, B, and C are incorrect because they do not accurately reflect the primary acid-base disturbance and the compensatory response seen in the given results.

4. Electrolytes:

• A. do not form when glucose is added to water.
• B. dissociate in water solutions, but do not form ions.
• C. form ions in water solutions, but do not necessarily dissociate.
• D. dissociate in water solutions and form ions in water solutions.

Correct answer: D

Rationale: The correct answer is D. Electrolytes are substances that dissociate into ions when dissolved in water, allowing the solution to conduct electricity. Choice A is incorrect because glucose does not form electrolytes when added to water. Choice B is incorrect as it states that electrolytes dissociate but do not form ions, which is inaccurate as electrolytes do form ions in water solutions. Choice C is also incorrect as it states that electrolytes form ions but may not necessarily dissociate, which goes against the definition of electrolytes that must dissociate into ions for conductivity. Therefore, choice D is the most accurate as it correctly describes that electrolytes dissociate in water solutions and form ions, highlighting the essential characteristics of electrolytes.

5. A nurse teaches a client who is being discharged home with a peripherally inserted central catheter (PICC). Which statement should the nurse include in this clients teaching?

• A. avoid carrying your grandchild with the arm that has the central catheter.
• B. Be sure to place the arm with the central catheter in a sling during the day
• C. Flush the peripherally inserted central catheter line with normal saline daily.
• D. You can use the arm with the central catheter for most activities of daily living.

Correct answer: A

Rationale:

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