Nursing Elites

1. Post thyroidectomy the nurse assesses for complications by performing which of the following assessments?

• A. Accu-Chek
• B. Chvostek's
• C. Ballottement
• D. Ice water colonic

Correct answer: B

Rationale: The correct answer is Chvostek's. A positive Chvostek's and Trousseau's sign is indicative of tetany, which is associated with low calcium levels. This can occur if parathyroid glands are accidentally removed during thyroidectomy. Accu-Chek is a brand of blood glucose monitor used for checking blood sugar levels and is not relevant in this context. Ballottement is a technique used in physical examination to assess for fluid in the body, typically in the abdomen or joints. Ice water colonic is not a standard medical assessment and is not relevant to post-thyroidectomy complications.

2. Acyclovir is the drug of choice for:

• A. HIV
• B. HSV 1 and 2 and VZV
• C. CMV
• D. influenza A viruses

Correct answer: C

Rationale: Acyclovir (Zovirax) is specifically used to treat infections caused by herpes simplex virus types 1 and 2 (HSV-1 and HSV-2) and varicella-zoster virus (VZV). These include conditions like cold sores, genital herpes, and shingles. Acyclovir works by inhibiting viral DNA replication, leading to the formation of shorter, ineffective DNA chains. It is important to note that acyclovir is not effective against other viruses like HIV, cytomegalovirus (CMV), or influenza A viruses. Therefore, the correct answer is HSV 1 and 2 and VZV.

3. What do the following ABG values indicate: pH 7.38, PO2 78 mmHg, PCO2 36 mmHg, and HCO3 24 mEq/L?

• A. metabolic alkalosis
• B. homeostasis
• C. respiratory acidosis
• D. respiratory alkalosis

Correct answer: B

Rationale: The correct answer is 'homeostasis.' These ABG values fall within the normal range, indicating a state of balance and homeostasis. The pH is within the normal range (7.35-7.45), the PCO2 is normal (35-45 mmHg), and the HCO3 level is also normal (22-26 mEq/L). Choice A, 'metabolic alkalosis,' is incorrect because the pH, PCO2, and HCO3 levels are not indicative of metabolic alkalosis. Choice C, 'respiratory acidosis,' is incorrect as the pH and PCO2 values are not elevated. Choice D, 'respiratory alkalosis,' is incorrect as the pH and PCO2 levels are not decreased. Therefore, the ABG values provided do not correspond to any acid-base disturbance, confirming that the patient is in a state of homeostasis.

4. A client with sleep apnea has been ordered a CPAP machine. Which action could the RN delegate to a nursing assistant?

• A. Reminding the client to apply the CPAP at bedtime
• B. Obtaining every three-hour oxygen saturation levels
• C. Teaching the client how to turn on the CPAP machine
• D. Assessing for fatigue or depression caused by poor sleep

Correct answer: A

Rationale: The correct answer is reminding the client to apply the CPAP at bedtime. This task can be safely delegated to a nursing assistant as it involves a simple and routine reminder. Option B, obtaining oxygen saturation levels, requires a higher level of training and interpretation of results, making it more appropriate for an RN. Option C, teaching the client how to turn on the CPAP machine, involves educating the client and ensuring proper use of medical equipment, which is within the RN's scope of practice. Option D, assessing for fatigue or depression, requires a comprehensive evaluation that involves interpreting symptoms and identifying underlying causes, making it more suitable for an RN to address.

5. One of the major functions of the kidneys in maintaining normal fluid balance is:

• A. the manufacture of antidiuretic hormone.
• B. the regulation of calcium and phosphate balance.
• C. the regulation of the pH of the extracellular fluid.
• D. the control of aldosterone levels.

Correct answer: C

Rationale: The correct answer is 'the regulation of the pH of the extracellular fluid.' The kidneys play a crucial role in maintaining normal fluid balance by regulating extracellular fluid and osmolarity through selective retention and excretion of fluids. Additionally, they regulate the pH of the extracellular fluid by retaining hydrogen ions and excreting metabolic wastes and toxic substances. Choice A is incorrect because antidiuretic hormone (ADH) is manufactured by the pituitary gland, not the kidneys. Choice B is incorrect as the regulation of calcium and phosphate balance is primarily controlled by the parathyroid gland. Choice D is incorrect as aldosterone levels are controlled by the adrenal glands, not the kidneys.

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