Nursing Elites

1. The nurse caring for a patient post colon resection is assessing the patient on the second postoperative day. The nasogastric tube (NG) remains patent and continues at low intermittent wall suction. The IV is patent and infusing at 125 mL/hr. The patient reports pain at the incision site rated at a 3 on a 0-to-10 rating scale. During your initial shift assessment, the patient complains of cramps in her legs and a tingling sensation in her feet. Your assessment indicates decreased deep tendon reflexes (DTRs) and you suspect the patient has hypokalemia. What other sign or symptom would you expect this patient to exhibit

• A. Diarrhea
• B. Dilute urine
• C. Increased muscle tone
• D. Joint pain

Correct answer: B

Rationale:

2. How would a decrease in blood protein concentration impact the fluid volumes?

• A. increase interstitial fluid volume.
• B. decrease blood plasma volume.
• C. decrease interstitial fluid volume.
• D. increase interstitial fluid volume and decrease blood plasma volume.

Correct answer: D

Rationale: A decrease in blood protein concentration would lead to a reduction in osmotic pressure, which is responsible for drawing fluid back into the capillaries. This decrease in osmotic pressure would result in an increase in interstitial fluid volume as fluid moves out of the capillaries, and a decrease in blood plasma volume as less fluid is drawn back into the circulation. Therefore, the correct answer is to increase interstitial fluid volume and decrease blood plasma volume. Choices A, B, and C are incorrect because they do not reflect the impact of decreased blood protein concentration on fluid volumes.

3. A patient with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause

• A. Respiratory acidosis
• B. Respiratory alkalosis
• C. Increased PaCO2
• D. CNS disturbances

Correct answer: B

Rationale:

4. You are caring for a patient with a secondary diagnosis of hypermagnesemia. What assessment finding would be most consistent with this diagnosis?

• A. Hypertension
• B. Kussmaul respirations
• C. Increased DTRs
• D. Shallow respirations

Correct answer: D

Rationale:

5. The physician has ordered a peripheral IV to be inserted before the patient goes for computed tomography. What should the nurse do when selecting a site on the hand or arm for insertion of an IV catheter?

• A. Choose a hairless site if available.
• B. Consider potential effects on the patients mobility when selecting a site.
• C. Have the patient briefly hold his arm over his head before insertion
• D. Leave the tourniquet on for at least 3 minutes.

Correct answer: B

Rationale:

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