Nursing Elites

1. A patient with diabetes insipidus is admitted to the intensive care unit after a motor vehicle accident that resulted in head trauma and damage to the pituitary gland. Diabetes insipidus can occur when there is a decreased production of which of the following?

• A. ADH
• B. Estrogen
• C. Aldosterone
• D. Renin

Correct answer: A

Rationale: The correct answer is A: ADH. Diabetes insipidus is characterized by a deficiency in antidiuretic hormone (ADH), leading to excessive urine output and thirst. In this scenario, the head trauma and damage to the pituitary gland can result in decreased production or release of ADH. Estrogen (Choice B) is not directly related to diabetes insipidus. Aldosterone (Choice C) is a hormone that regulates sodium and potassium levels, not water balance like ADH. Renin (Choice D) is an enzyme involved in the regulation of blood pressure and fluid balance but not directly related to diabetes insipidus.

2. A nurse assesses a client who is admitted for treatment of fluid overload. Which manifestations should the nurse expect to find? (Select all that do not apply.)

• A. Increased pulse rate
• B. . Distended neck veins
• C. Warm and pink skin
• D. Skeletal muscle weakness

Correct answer: C

Rationale:

3. The nurse who assesses the patient's peripheral IV site and notes edema around the insertion site will document which complication related to IV therapy?

• A. Air emboli
• B. Phlebitis
• C. Infiltration
• D. Fluid overload

Correct answer: C

Rationale: Infiltration is the administration of non-vesicant solution or medication into the surrounding tissue. This can occur when the IV cannula dislodges or perforates the vein's wall. Infiltration is characterized by edema around the insertion site, leakage of IV fluid from the insertion site, discomfort, and coolness in the area of infiltration, and a significant decrease in the flow rate. Air emboli (Choice A) involves air entering the bloodstream. Phlebitis (Choice B) is inflammation of a vein. Fluid overload (Choice D) is an excessive volume of fluid in the circulatory system.

4. A nurse is caring for a client who is experiencing excessive diarrhea. The clients arterial blood gas values are pH 7.28, PaO2 98 mm Hg, PaCO2 45 mm Hg, and HCO3 16 mEq/L. Which provider order should the nurse expect to receive?

• A. Furosemide (Lasix) 40 mg intravenous push
• B. Sodium bicarbonate 100 mEq diluted in 1 L of D5W
• C. Mechanical ventilation
• D. Indwelling urinary catheter

Correct answer: B

Rationale:

5. During a visit to an 84-year-old woman recovering from hip surgery, the nurse notices signs of confusion and poor skin turgor. The woman mentions she limits water intake to avoid nighttime bathroom trips. The nurse should explain to the woman that:

• A. She will need her medications adjusted and be readmitted for a complete workup.
• B. Limiting fluids can lead to body imbalances causing confusion; perhaps adjusting fluid intake timing is necessary.
• C. Post-surgical confusion is common, and it's safe not to urinate at night.
• D. Confusion after surgery is typical in the elderly due to sleep loss.

Correct answer: B

Rationale: The correct answer is B. In elderly patients, fluid and electrolyte imbalances can manifest with subtle signs like confusion. Limiting fluids can lead to such imbalances, affecting cognitive function. Adjusting the timing of fluid intake can help maintain hydration without causing nighttime disruptions. Choices A, C, and D are incorrect. Choice A suggests unnecessary hospital readmission and medication adjustments without addressing the root cause. Choice C wrongly normalizes the confusion and fails to address the potential issue of fluid restriction. Choice D incorrectly attributes confusion solely to sleep loss without considering the impact of fluid balance.

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